Turkey - Demographic and Health Survey - 2004

Publication date: 2004

Turkey Demographic and Health Survey 2003 Hacettepe University Institute of Population Studies Ankara, Turkey with the contributions of General Directorate of Mother and Child Health / Family Planning, Ministry of Health, Ankara, Turkey Co-funded by T.R. Prime Ministry State Planning Organization European Union October 2004 The contents of this document are the sole responsibility of Hacettepe University Institute of Population Studies and can under no circumstances be regarded as reflecting the position of the European Union. The 2003 Turkey Demographic and Health Survey (TDHS-2003) was carried out by the Hacettepe University Institute of Population Studies in collaboration with the General Directorate of Mother and Child Health and Family Planning of the Ministry of Health. Initial funding for the TDHS-2003 was provided by the Government of Turkey, as a project in the annual investment program of the State Planning Organization. Further funding was provided by the European Union through the Turkey Reproductive Health Program implemented by the Ministry of Health. TDHS-2003 is fully comparable with the models and standards developed by the worldwide Demographic and Health Surveys (MEASURE/DHS+) project. Macro International Inc. provided technical assistance on the review and formatting of the final report. Additional information about the TDHS-2003 may be obtained from Hacettepe University, Institute of Population Studies, 06100 Ankara, Turkey (telephone:312-310-7906; fax: 312-311-8141; e-mail: hips@hacettepe.edu.tr; internet: www.hips.hacettepe.edu.tr). Information about the MEASURE/DHS+ project may be obtained from ORC Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-572-0999; e-mail: reports@macroint.com; internet: www.measuredhs.com). Suggested citation: Hacettepe University Institute of Population Studies, Turkey Demographic and Health Survey, 2003. Hacettepe University Institute of Population Studies, Ministry of Health General Directorate of Mother and Child Health and Family Planning, State Planning Organization and European Union. Ankara, Turkey Table of Contents i TABLE OF CONTENTS List of Tables and Figures .v Foreword. xi Summary of Findings .xv Map of Turkey.xx CHAPTER 1 INTRODUCTION 1.1 Geography .1 1.2 History .1 1.3 Administrative Divisions and Political Organization.3 1.4 Social and Cultural Features.3 1.5 Economy.4 1.6 Regional Divisions .6 1.7 Population.7 1.8 Population and Family Planning Policies and Programs.9 1.9 Health Priorities and Programs.10 1.10 Health Care System in Turkey .10 1.11 Objectives and Organization of the Survey.11 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Characteristics of the Household Population .17 2.2 Fosterhood and Orphanhood .20 2.3 Education of the Household Population .21 2.4 Housing Characteristics.29 2.5 Household Durable Goods .31 CHAPTER 3 WOMEN’S CHARACTERISTICS AND STATUS 3.1 Background Characteristics.33 3.2 Respondents’ Level of Education by Background Characteristics .35 3.3 Employment and Occupation .36 3.4 Decision on Use of Earnings .38 3.5 Domestic Violence: Women’s Attitudes towards Being Subject to Physical Violence .40 3.6 Child Care While Working.42 Table of Contents ii CHAPTER 4 FERTILITY 4.1 Current Fertility .45 4.2 Fertility Differentials .47 4.3 Fertility Trends .49 4.4 Children Ever Born and Living .52 4.5 Birth Intervals.53 4.6 Age at First Birth .55 4.7 Teenage Pregnancy and Motherhood .57 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Family Planning Methods.59 5.2 Ever Use of Family Planning Methods .62 5.3 Current Use of Contraception.63 5.4 Trends in Current Use of Family Planning.65 5.5 Number of Children at First Use of Contraception .67 5.6 Knowledge of the Fertile Period.68 5.7 Timing of Female Sterilization.69 5.8 Sources for Family Planning Methods .70 5.9 Informed Choice.72 5.10 Discontinuation of Contraceptive Use.74 5.11 Intention to Use Contraception Among Non-Users .75 5.12 Reasons for Non-Use of Contraception.77 CHAPTER 6 ABORTIONS AND STILLBIRTHS 6.1 Life-time Experience with Pregnancy Terminations.79 6.2 Current Levels and Trends in Abortion Rates.80 6.3 Patterns of Contraceptive Use Prior to and After Induced Abortion.83 6.4 Reasons for Induced Abortion.84 6.5 Timing of Induced Abortion.86 6.6 Abortion Provider.86 6.7 Age-specific and Total Abortion Rates .87 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY 7.1 Current Marital Status .89 7.2 Age at First Marriage.90 7.3 Postpartum Amenorrhea, Postpartum Abstinence, and Insusceptibility .93 Table of Contents iii CHAPTER 8 FERTILITY PREFERENCES 8.1 Desire for More Children .97 8.2 Need for Family Planning Services.101 8.3 Ideal Number of Children.101 8.4 Planning Status of Births .104 CHAPTER 9 INFANT AND CHILD MORTALITY 9.1 Assessment of Data Quality .107 9.2 Levels and Trends in Infant and Child Mortality .109 9.3 Differentials in Infant and Child Mortality .110 9.4 Perinatal Mortality.113 9.5 High-risk Fertility Behaviour .114 CHAPTER 10 ANTENATAL CARE AND DELIVERY ASSISTANCE 10.1 Antenatal Care .117 10.2 Number and Timing of Antenatal Care Visits.120 10.3 Components of Antenatal Care .121 10.4 Place of Delivery and Assistance During Delivery.123 10.5 Characteristics of Delivery .127 CHAPTER 11 VACCINATION AND CHILD HEALTH 11.1 Vaccination of Children .131 11.2 Prevalence and Treatment of Acute Respiratory Infection and Fever.135 11.3 Smoking Status of Mothers .137 CHAPTER 12 INFANT FEEDING PRACTICES AND CHILDREN’S AND WOMEN’S NUTRITIONAL STATUS 12.1 Initiation of Breastfeeding.139 12.2 Breastfeeding Status by the Age of Child .141 12.3 Duration and Frequency of Breastfeeding.143 12.4 Types of Complementary Food .144 12.5 Iodization of Household Salt .146 12.6 Nutritional Status of Children .147 12.7 Nutritional Status of Mother.151 CHAPTER 13 KNOWLEDGE OF HIV/AIDS 13.1 Knowledge of AIDS and Other STDs .155 13.2 Sources of Information about AIDS.157 Table of Contents iv 13.3 Knowledge of Ways to Prevent AIDS.158 13.4 Perception of Risk of AIDS.161 REFERENCES.163 APPENDIX A LIST OF PERSONNEL .165 APPENDIX B SURVEY DESIGN.167 B.1 Sample Design and Implementation.167 B.2 Sample Frame.168 B.3 Stratification .168 B.4 Sample Allocation .171 B.5 Sample Selection .172 B.6 Questionnaire Development and Pretest .174 B.7 Data Collection Activities .176 B.8 Data Processing and Analysis .177 B.9 Calculation of Sample Weights .178 B.10 Coverage of the Sample.183 APPENDIX C SAMPLING ERRORS .187 APPENDIX D QUALITY OF THE DATA .211 APPENDIX E QUESTIONNAIRES.219 List of Tables and Figures | v LIST OF TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews.15 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence.18 Table 2.2 Population by age from selected sources .19 Table 2.3 Household composition.20 Table 2.4 Children's living arrangements and orphanhood.21 Table 2.5.1 Educational attainment of household population: males.23 Table 2.5.2 Educational attainment of household population: females .24 Table 2.6 School attendance ratios.26 Table 2.7.1 Grade repetition rates .28 Table 2.7.2 Grade dropout rates .29 Table 2.8 Household characteristics.30 Table 2.9 Household durable goods .32 Figure 2.1 Population Pyramid .18 Figure 2.2 Age-specific Attendance Rates .25 CHAPTER 3 WOMEN’S CHARACTERISTICS AND STATUS Table 3.1 Background characteristics of respondents .34 Table 3.2 Educational attainment by background characteristics .35 Table 3.3 Employment status .37 Table 3.4 Decision on use of earnings and contribution of earnings to household expenditures .39 Table 3.5 Women's control over earnings .40 Table 3.6 Women’s attitude toward wife beating .41 Table 3.7 Child care while working .43 CHAPTER 4 FERTILITY Table 4.1 Current fertility.46 Table 4.2 Fertility by background characteristics .48 Table 4.3 Trends in fertility.49 Table 4.4 Age-specific fertility rates .50 Table 4.5 Fertility by marital duration .51 vi | List of Tables and Figures Table 4.6 Children ever born and living.52 Table 4.7 Birth intervals .54 Table 4.8 Age at first birth .55 Table 4.9 Median age at first birth by background characteristics.56 Table 4.10 Teenage pregnancy and motherhood.58 Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence .47 Figure 4.2 Trends in Fertility.50 Figure 4.3 Age-specific Fertility Rates during the Last 20 Years .51 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods .60 Table 5.2 Knowledge of contraceptive methods by background characteristics .61 Table 5.3 Ever use of contraception.62 Table 5.4 Current use of contraception .63 Table 5.5 Current use of contraception by background characteristics .64 Table 5.6 Trends in current use of contraception.66 Table 5.7 Trends in current use of contraception by residence and region.67 Table 5.8 Number of children at first use of contraception.68 Table 5.9 Knowledge of the fertile period .69 Table 5.10 Timing of sterilization.69 Table 5.11 Source of supply for modern contraceptive methods.70 Table 5.12 Trends in source of supply for selected modern methods .72 Table 5.13 Informed choice.73 Table 5.14 Contraceptive discontinuation rates .74 Table 5.15 Reasons for discontinuation of contraception .75 Table 5.16 Future use of contraception .76 Table 5.17 Preferred method of contraception for future use .76 Table 5.18 Reasons for not using contraception .77 Figure 5.1 Current Use of Family Planning by Region and Method.65 Figure 5.2 Current Use of Family Planning Methods, Turkey 1993, 1998, and 2003 .66 Figure 5.3 Source of Modern Contraceptive Methods .71 CHAPTER 6 ABORTIONS AND STILLBIRTHS Table 6.1 Number of abortions and stillbirths.80 Table 6.2 Induced abortions by background characteristics .81 Table 6.3 Abortions and stillbirths per 100 pregnancies.82 Table 6.4 Trends in induced abortions .82 Table 6.5 Method used before abortion.83 Table 6.6 Method used after abortion .83 Table 6.7 Reasons for induced abortion.85 Table 6.8 Timing of induced abortion.86 Table 6.9 Abortion provider .87 List of Tables and Figures | vii Table 6.10 Total abortion rates.87 Table 6.11 Total abortion rates by background characteristics.88 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 7.1 Current marital status .90 Table 7.2 Age at first marriage.91 Table 7.3 Median age at first marriage.92 Table 7.4 Postpartum amenorrhea, abstinence, and insusceptibility.94 Table 7.5 Median duration of postpartum insusceptibility by background characteristics.96 Figure 7.1 Marital Status of Women Age 15-49 .90 Figure 7.2 Median Age at First Marriage among Women Age 25-49.93 Figure 7.3 Percentage of Births Whose Mothers are Amenorrheic, Abstaining, or Insusceptible.95 CHAPTER 8 FERTILITY PREFERENCES Table 8.1 Fertility preference by number of living children .98 Table 8.2 Fertility preference by age.99 Table 8.3 Desire to limit (stop) childbearing .100 Table 8.4 Need for family planning services .102 Table 8.5 Ideal and actual number of children.103 Table 8.6 Mean ideal number of children by background characteristics.104 Table 8.7 Fertility planning status.105 Table 8.8 Wanted fertility rates .106 Figure 8.1 Fertility Preferences of Currently Married Women Age 15-49 .99 CHAPTER 9 INFANT AND CHILD MORTALITY Table 9.1 Infant and child mortality .109 Table 9.2 Early childhood mortality rates by socioeconomic characteristics .111 Table 9.3 Early childhood mortality rates by biodemographic characteristics .112 Table 9.4 Perinatal mortality .113 Table 9.5 High-risk fertility behavior.115 Figure 9.1 Trends in Infant Mortality: Estimates for 5-Year Periods Preceding the TDHS-1993, TDHS-1998, and TDHS-2003.110 CHAPTER 10 ANTENATAL CARE AND DELIVERY ASSISTANCE Table 10.1 Antenatal care.118 Table 10.2 Number of antenatal care visits and timing of first visit .121 Table 10.3 Components of antenatal care .122 Table 10.4 Place of delivery.124 viii | List of Tables and Figures Table 10.5 Assistance during delivery .127 Table 10.6 Delivery characteristics .129 Figure 10.1 Antenatal Care by Maternal Age and Birth Order .119 Figure 10.2 Antenatal Care by Residence and Region .120 Figure 10.3 Place of delivery by Maternal Age and Birth Order .125 CHAPTER 11 VACCINATION AND CHILD HEALTH Table 11.1 Vaccinations by source of information .132 Table 11.2 Vaccinations by background characteristics .133 Table 11.3 Vaccinations in first year of life by current age .134 Table 11.4 Prevalence and treatment of symptoms of ARI and fever .136 Table 11.5 Use of smoking cigarettes .138 CHAPTER 12 INFANT FEEDING PRACTICES AND CHILDREN’S AND WOMEN’S NUTRITIONAL STATUS Table 12.1 Initial breastfeeding.140 Table 12.2 Breastfeeding status by age .142 Table 12.3 Median duration and frequency of breastfeeding.144 Table 12.4 Types of food received by children in the preceding 24 hours .145 Table 12.5 Iodization of household salt .146 Table 12.6 Nutritional status of children by background characteristics .149 Table 12.7 Anthropometric indicators of maternal nutritional status .151 Table 12.8 Nutritional status of women by background characteristics .153 Figure 12.1 Nutritional Status of Children by Age.150 CHAPTER 13 KNOWLEDGE OF AIDS Table 13.1 Knowledge of AIDS and other STDs.156 Table 13.2 Source of AIDS information .158 Table 13.3 Knowledge of ways to avoid HIV/AIDS .159 Table 13.4 Ways to avoid AIDS by background characteristics.160 Table 13.5 Knowledge of HIV/AIDS-related issues.162 APPENDIX B SURVEY DESIGN Table B.1 List of strata by region, NUTS 1 region, residence, type and province .169 Table B.2 Allocation of sample households .171 Table B.3 Distribution of sample clusters.172 Table B.4 Stages of fieldwork, completed number of clusters in each stage, and number of teams in each stages.177 Table B.5.1 Design weights and nonresponse factors .180 List of Tables and Figures | ix Table B.5.2 Design weights and nonresponse factors: half sample.181 Table B.6 Final sample weights .182 Table B.7.1 Sample implementation according to residence and region.184 Table B.7.2 Sample implementation according to NUTS 1 regions.185 APPENDIX C SAMPLING ERROS Table C.1 List of selected variables for sampling errors .190 Table C.2 Sampling errors: National Sample .191 Table C.3 Sampling errors: Urban Areas.192 Table C.4 Sampling errors: Rural Areas .193 Table C.5 Sampling errors: West Region .194 Table C.6 Sampling errors: South Region .195 Table C.7 Sampling errors: Central Region.196 Table C.8 Sampling errors: North Region .197 Table C.9 Sampling errors: East Region.198 Table C.10 Sampling errors: İstanbul .199 Table C.11 Sampling errors: West Marmara Region.200 Table C.12 Sampling errors: Aegean Region .201 Table C.13 Sampling errors: East Marmara Region .202 Table C.14 Sampling errors: West Anatolia Region.203 Table C.15 Sampling errors: Mediterranean Region .204 Table C.16 Sampling errors: Central Anatolia Region .205 Table C.17 Sampling errors: West Black Sea Region .206 Table C.18 Sampling errors: East Black Sea Region.207 Table C.19 Sampling errors: Northeast Anatolia Region .208 Table C.20 Sampling errors: Central East Anatolia Region .209 Table C.21 Sampling errors: Southeast Anatolia Region .210 APPENDIX D QUALITY OF THE DATA Table D.1 Age distribution of de facto household population .213 Table D.2 Age distribution of eligible and interviewed women .214 Table D.3 Completeness of reporting .214 Table D.4 Births by calendar years .215 Table D.5 Reporting of age at death in days .216 Table D.6 Reporting of age at death in months.217 Foreword | xi FOREWORD Hacettepe University Institute of Population Studies was established in 1967 and is the principal institution carrying out nationwide scientific studies on fertility, mortality, migration and maternal and child health issues in Turkey. Through a series of national household surveys conducted every five years, our Institute has collected highly reliable data nationwide on population characteristics and maternal and child health since 1968. These data have allowed the demographic situation in Turkey to be assessed regularly for about a four-decade period. They have been the basis on which population and health policies have been formed, service plans prepared, and the coverage and impact of these plans monitored. The 2003 Turkey Demographic and Health Survey (TDHS-2003) is the eighth national survey carried out by the Institute of Population Studies. It is a honor for our Institute to win the general approval and confidence of all people and institutions at national and international level with such a program of continuous high quality data production and successful application. The seven Demographic and Health Surveys between 1968-1998 were financially supported by various international sources. However, for the first time, the TDHS-2003 was financed by the national budget of Republic of Turkey, and further support was provided by the European Union through the reproductive health programme. This is an indicator of institutionalization and the importance of this issue in our country. Preparatory activities of the TDHS-2003 began in 2002. In the same year, a qualitative research study was conducted involving in-depth interviews with women on contraceptive use, its dynamics and induced abortion. The results of this research were presented in a meeting in April 2003, in which representatives of various organizations interested in these data participated. In the months that followed, activities relating to sampling and questionnaire design continued. Following the completion of the preparatory activities, listing and fieldwork took place between November 2003 and May 2004. The TDHS-2003 was conducted in 80 provinces and 700 places of residence which were selected in such fashion as to represent our country nationally and at the urban-rural and regional levels. Interviews were carried out with 8,075 ever-married women in 10,836 households. In June 2004, the preliminary report that included some key indicators calculated from the TDHS-2003 was published and disseminated to organizations concerned with population and maternal and child health issues. The results presented in this report show that there have been important changes in various demographic and health indicators in a more positive direction than expected. The fertility data indicate that Turkey is achieving “replacement” fertility. The survey findings also document improvements in infant and child mortality and progress in mother and child health services. xii | Foreword The contributions of university directors, the directors and experts of the public institutions and personnel of our Institute were instrumental in the realization of various stages of the TDHS-2003. I would like to express my gratitude to them for their much appreciated efforts. First of all, I would like to thank to Kemal Madenoğlu, the General Director of the State Planning Organization, and his staff who provided the financial source for the TDHS- 2003 through the national budget by putting the survey in the investment program of 2002 for the first time and who continued their supports unstintingly through the survey. I would like to express my gratitude to the Delegation of the European Union to Turkey and to Simon Mordue, the director of Financial Cooperation, Coordination and Investment, for additional financial source they provided when the financial resource from the national budget was not sufficient for the extended objectives and coverage of the survey. I would like to thank also Figen Tunçkanat for her efforts in designing and executing the project. The Ministry of Health provided extensive support the TDHS-2003 in every stage as in the previous Demographic and Health Surveys conducted by our Institute. I deeply appreciate first Prof. Dr. Recep Akdağ, the Minister of Health, and especially Dr. Mehmet Rifat Köse, General Director of the Mother and Child Health and Family Planning and his deputy Dr. M. Ali Biliker for their productive, supportive, analytical and enriching contributions. Moreover, I would like to also acknowledge the efforts of other directors and personnel in the General Directorate as well as the health directors and other health personnel in the provinces where the survey was carried out. I would like to thank Assoc. Prof. Dr. Ömer Demir, the President of the State Institute of Statistics, and Hasibe Dedeş, the director of the Survey, Analysis and Statistics Division, and other staff for their efforts and contributions in selecting the sample with scientific sensitivity. I am grateful to Ministry of Interior that provided the necessary permissions for field survey as well as province governors who supported the implementation of the survey and other province directors for their contributions. My special thanks go to Prof. Dr. Tunçalp Özgen, the Rector of Hacettepe University and authorities in the Scientific Research Unit of the University as they shared all the difficulties with us and gave valuable support in every stage of the TDHS-2003. My thanks are also due to the Steering Committee Members for their valuable contributions. I deeply appreciate all respondents who accepted to be involved in the survey and answered the questionnaires and all the team staff worked in the field, without them we were unable to conduct this survey. I would like to thank Han Raggers who ensured the data file which is a part of a structure that guarantees the TDHS-2003 be in the context of International Demographic and Foreword | xiii Health Surveys, and to Dr. Ann A. Way, the deputy director of the MEASURE DHS Program at ORC Macro and her colleagues for their important efforts in finalization of this report. We also appreciate USAID’s willingness to support the MEASURE team’s involvement in the report preparation. Finally, I extend my deepest gratitude to the technical director of the TDHS-2003 Assoc. Prof. Dr. Banu Ergöçmen, the field director Assoc. Prof. Dr. İsmet Koç, and Assoc. Prof. Dr. Attila Hancıoğlu, Assoc. Prof. Dr. Turgay Ünalan and Dr. A. Sinan Türkyılmaz who are responsible for sampling, questionnaire design, data entry and data analysis, as well as research assistants and administrative staff for their efforts. Moreover, I present my appreciation and respect to all our family members for their support and indulgence during the laborious times in and out of work days. Prof. Dr. Sabahat Tezcan Director Institute of Population Studies Hacettepe University Summary of Findings | xv SUMMARY OF FINDINGS The 2003 Turkey Demographic and Health Survey (TDHS-2003) is a nationally repre- sentative sample survey designed to provide information on levels and trends on fertility, infant and child mortality, family planning and maternal and child health. Survey re- sults are presented at the national level, by urban and rural residence, and for each of the five regions in the country. The TDHS- 2003 sample also allows analyses for some of the survey topics for the 12 geographical regions (NUTS1) which were adopted at the second half of 2002 within the context of Turkey’s move to join the European Union. Funding for the TDHS-2003 was provided initially by the Government of Turkey, as a project in the annual investment program of the State Planning Organization, and further funding was obtained from the European Union through the Turkey Reproductive Health Program implemented by the Minis- try of Health. Hacettepe University Institute of Population Studies (HUIPS) carried out the TDHS-2003 in collaboration with the General Directorate of Mother and Child Health and Family Planning, Ministry of Health. TDHS-2003 is the most recent in the series of demographic surveys carried out in Turkey by HUIPS and it is the third survey conducted as part of the worldwide Demographic and Health Sur- veys program. The survey was fielded between December 2003 and May 2004. Interviews were com- pleted with 10,836 households and with 8,075 ever-married women at reproductive ages (15-49). Ever-married women at ages 15-49 who were present in the household on the night before the interview or who usu- ally live in that household were eligible for the survey. CHARACTERISTICS OF HOUSEHOLD POPULATION Turkey has a young population structure; 29 percent of the population is under age 15. The population age 65 and over accounts for 7 percent of the total population in Turkey. The mean household size in Turkey is 4 per- sons, varying from an average of 3.9 persons in the urban areas to 4.5 persons in rural ar- eas. The majority of the population in Turkey has attended school. Among the population with schooling, about one-third of both males and females have completed at least second level primary school. The proportion of population with at least high school edu- cation is 23 percent for males and 14 per- cent for females. However, the indicators for successive cohorts show a substantial in- crease over time in the educational attain- ment of both men and women. CHARACTERISTICS OF RESPONDENTS A third of women interviewed in the TDHS- 2003 were less than 30 years of age; ninety- five percent were married at the time of interview. A significant proportion of women (17 percent) had completed at least high school. Survey results show considerable improvement in the educational levels of women in reproductive ages. While 42 percent of women had been in employment during the 12 month period xvi | Summary of Findings preceding the survey, women’s earnings meet almost none or less than half of the expenditures of households for 6 in 10 cases. Independent decision making with regard to the use of earnings show variation according to age, place of residence and level of education of women. FERTILITY BEHAVIOR Levels and Trends The findings of the TDHS-2003 indicate that if a woman was to maintain the current fer- tility rates throughout her reproductive years, she would be expected to have 2.2 children on the average by the end of her reproductive years. Women in Turkey ex- perience their prime reproductive years during their twenties with age-specific fertility peaking in the 20-29 age group. Fertility has fallen sharply in Turkey over the past several decades. Socioeconomic and Demographic Differentials The urban-rural gap in fertility levels appears to be closing. However, some re- gional differences remain. Except for South and East Anatolia, fertility is below replace- ment level. Despite a pronounced decline in fertility in recent decades, period fertility in the East is still well above three children. Fertility decreases rapidly with increasing educational level. Women with no education have on average two more children than that of women who have high school and more education. Another important trend is the steady rise in the age at first birth among women in Turkey. Younger women are much less likely than older women to have given birth to their first child while they were in their teens. Age at Marriage In Turkey, marriage is very important from a demographic perspective, because, besides being prevalent throughout the country, almost all births occur within marriage. Therefore, age at first marriage is a significant demographic indicator since it represents the onset of a woman’s exposure to the risk of pregnancy. The TDHS-2003 results document an in- crease in the median age at first marriage across age cohorts, from 19.2 years for the 45-49 age group to 21 years for the 25-29 age group. The results also show pro- nounced differences in the age at first mar- riage by educational level of women. Among women age 25-49 there is a differ- ence of almost seven years in the timing of entry into marriage between those with no education and those who has at least high school education. FAMILY PLANNING USE Family Planning Knowledge Knowledge of family planning methods is almost universal among women in Turkey. Almost all women interviewed in the survey had heard of at least one modern method. The IUD and pill are the most widely known modern contraceptive methods among women followed by the male condom, fe- male sterilization and injectables. Levels and Trends Ninety percent of both ever-married and cur- rently married women have used a family planning method at some time in their life. Overall, 71 percent of currently married women are using contraception, with 43 per- cent depending on modern methods and 29 percent using traditional methods. The IUD is the most widely used modern method (20 percent) followed by male condom (11 per- cent). Withdrawal continues to be the most widely used traditional method. Twenty six percent of currently married women report current use of withdrawal. Summary of Findings | xvii Differentials in Use The use of contraceptive methods varies by age. Current use of any method is the high- est among currently married women (81 percent) in the 30-34 age group. The use of withdrawal peaks among women in the 40- 44 age group (50 percent) while the highest level of IUD use (26 percent) is found among women age 30-34. Current use of contraceptive methods also varies according to urban rural residence, region, level of education, and number of living children. Discontinuation of Use Discontinuation of contraceptive use can highlight program areas that require im- provement as well as groups of users who have particular concerns that need to be ad- dressed. The TDHS-2003 results indicate that 40 percent of contraceptive users in Turkey stop using a contraceptive method within 12 months of starting use. The IUD, which is not generally intended as a short- term method, has the lowest discontinuation rate (11 percent). Coitus-related methods are more easily discontinued. For example, 45 percent of condom users discontinue within one year of use. Regarding future use, almost half of currently married non-users intend to use family planning at some time in the future. Provision of Services The public sector is the major source of con- traceptive methods in Turkey. Fifty-eight percent of current users obtain their contra- ceptives from the public sector. In the public sector one-third of the users obtain modern contraceptive methods from health centers or MCH/FP centers. Pharmacies are the second most commonly used source, pro- viding contraceptive methods to one-fourth of all users of modern methods. INDUCED ABORTION Overall, 22 percent of pregnancies during the five-year period before the survey termi- nated in other than a live birth. Induced and spontaneous abortions comprised the great- est share among non-live terminations, with relatively few women having had a stillbirth. There were 21 abortions per 100 pregnan- cies, of which 11 were induced. The total abortion rate (TAR) per woman is 0.4 for the five years preceding the TDHS-2003. The age-specific rates increase to a peak among women age 30-34, and decline among older women. Women living in the East region and in rural settlements are the least likely to have ever had an induced abortion. The main reason for obtaining an abortion is to stop childbearing (41 percent). Overall, a substantial proportion of abortions (73 per- cent) took place in the first month of preg- nancy. Private sector providers are preferred for having had an abortion (77 percent). The need for family planning counselling after an abortion is highlighted by the finding that, in the month following an induced abortion, 31 percent of women did not use any method and 26 percent used withdrawal. NEED FOR FAMILY PLANNING Fertility Preferences Sixty-nine percent of currently married women say they do not want to have more births in the future or are already sterilized for contraceptive purposes. An additional 14 percent of the women want to wait at least two years for another birth. Thus, four out of every five currently married women can be regarded as in need of using family planning services either to avoid or to postpone child- bearing. Among the currently married women, the mean ideal number of children is 2.5 for women indicating that most women want small families. Results from xviii | Summary of Findings the survey suggest that, if all unwanted births were prevented, the total fertility rate at the national level would be 1.6 children per woman, or 0.7 children less than the ac- tual total fertility rate. Unmet Need for Family Planning The total demand for family planning is 76 percent, and 92 percent of this demand is satisfied. The demand for limiting purposes is three times as high as the demand for spacing purposes (58 and 18 percent, re- spectively). The total unmet need among currently married women is 6 percent, lower than that recorded in the previous two surveys. CHILD MORTALITY Levels and Trends For the five years preceding the TDHS- 2003, the infant mortality rate is estimated at 29 per thousand, the child mortality rate at 9 per thousand, and the under five mortality rate at 37 per thousand. For the same period, results show that the neonatal mortality rate is higher than the postneonatal mortality rate. All the indicators of infant and child mortality have declined rapidly in recent years. Socioeconomic and Demographic Differ- entials The TDHS-2003 findings point out to significant differences in infant and child mortality between regions and by urban- rural residence. They also show that the educational level of mother is an important correlate of infant and child mortality. In addition to the differentials observed between socio-economic groups, infant and child mortality rates also correlate strongly with the young age of the mother at birth, high-birth order and short birth intervals, with children in these categories facing an elevated risk of dying compared to children in other subgroups. In addition, low weight at birth affects children’s chances of survival. MATERNAL HEALTH Care during Pregnancy Eighty-one percent of mothers received an- tenatal care during the pregnancy preceding their most recent birth in the five years pre- ceding the survey, with 75 percent receiving care from a doctor. Overall, 71 percent of women made an antenatal care visit before the sixth month of pregnancy, and more than half of the woman made more than four vis- its. Younger, low parity women, women living in urban areas and in the regions other than the East, and women with at least first primary level education are more likely to have received antenatal care compared to other women. Delivery Care and Postnatal Care In Turkey, 78 percent of all births in the five years preceding the survey were delivered at a health facility. Public sector health facili- ties were used to a much greater extent for delivery (65 percent) than private facilities. The proportion of all births delivered with the assistance of a doctor or trained health personnel is 83 percent. CHILD HEALTH Childhood Vaccination Coverage Universal immunization of children under one year of age against the six vaccine-pre- ventable diseases (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and mea- sles) is one of the most cost-effective pro- grams in reducing infant and child morbidity and mortality. Among children age 12-23 months, 54 percent of them had received all of the recommended eight vaccines. The percentage of children who were fully vac- cinated by 12 months of age was 48 percent. Summary of Findings | xix The percentage of children who are fully vaccinated is lowest in the rural areas and in the Eastern region. The vaccination cover- age percentages are also related to mother’s education and the children’s sex and birth order. Prevalence and Treatment of ARI Acute respiratory infection (ARI) is the most prevalent disease in Turkey among children under age five during winter months. In the two weeks preceding the survey, 29 percent of children had experienced ARI, and 40 percent had fever. Four in every ten children received some kind of treatment from a health facility or a health provider for these illnesses. Among all ever-married women age 15-49, 28 percent reported that they smoke regu- larly or rarely. According to maternity status, 15 percent of pregnant women and 20 percent of breastfeeding women report that they smoke. Smoking more than 10 ciga- rettes is most common among women age 35-49. NUTRITION INDICATORS FOR CHILDREN AND WOMEN Breastfeeding and supplemental feeding Breastfeeding is almost universal in Turkey; 97 percent of all children are breastfed for some period of time. Complementary feeding is common among very young children. In the first two months of life, only 44 percent are exclusively breastfed. The median dura- tion of breastfeeding for all children is 14 months. Among children who are breast- feeding and younger than six months, 18 per- cent received infant formula. Iodization of Salt Iodine deficiency contributes to higher rates of childhood morbidity and mortality. Ac- cording to tests conducted during the survey, the table salt in 30 percent of the households did include neither iodide nor iodate. Iodized salt is not used in about half of rural house- holds. Less than half of the households in Central and Southeast Anatolia use iodized salt. Nutritional Status of Children By age five, 12 percent 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. Wasting is a less serious problem. Four percent of children are underweight for their age. Obesity is a problem among mothers. Ac- cording to BMI calculations, 57 percent of mothers are overweight, of which 23 percent are obese. BMI increases rapidly with age, exceeding 25.0 for the majority of women age 25 and older. HIV/AIDS KNOWLEDGE AND ATTITUDES Awareness of acquired immune deficiency syndrome (AIDS) is high in Turkey. Ninety percent of women reported having heard of AIDS. Despite this widespread awareness, 31 percent of ever-married women do not know any way to avoid AIDS. Educational level is positively related to knowing about ways of avoiding AIDS. The percentage who knows HIV/AIDS is higher among ur- ban ever-married women than among their counterparts living in rural area. R EG IO N S A N D P R O VI N C ES 01 İS TA N B U L 04 E A ST 06 M ED IT ER R A N EA N 08 W ES T 10 N O R TH EA ST 12 S O U TH EA ST 34 İs ta nb ul M A R M A R A 01 A da na B LA C K S EA A N A TO LI A A N A TO LI A 02 W ES T 11 B ile ci k 07 A nt al ya 05 A m as ya 04 A ğr ı 02 A dı ya m an M A R M A R A 14 B ol u 15 B ur du r 18 Ç an kı rı 24 E rz in ca n 21 D iy ar ba kı r 10 B al ık es ir 16 B ur sa 31 H at ay 19 Ç or um 25 E rz ur um 27 G az ia nt ep 17 Ç an ak ka le 26 E sk iş eh ir 32 Is pa rta 37 K as ta m on u 36 K ar s 47 M ar di n 22 E di rn e 41 K oc ae li 33 İç el 55 S am su n 69 B ay bu rt 56 S iir t 39 K ırk la re li 54 S ak ar ya 46 K .M ar aş 57 S in op 75 A rd ah an 63 Ş an lıu rfa 59 T ek ird ağ 77 Y al ov a 80 O sm an iy e 60 T ok at 76 Iğ dı r 72 B at m an 03 A EG EA N 81 D üz ce 07 C EN TR A L 67 Z on gu ld ak 11 C EN TR A L EA ST 73 Ş ırn ak 03 A fy on 05 W ES T A N A TO LI A 74 B ar tın A N A TO LI A 79 K ili s 09 A yd ın A N A TO LI A 38 K ay se ri 78 K ar ab ük 12 B in gö l 20 D en iz li 06 A nk ar a 40 K ırş eh ir 09 E A ST 13 B itl is 35 İz m ir 42 K on ya 50 N ev şe hi r B LA C K S EA 23 E la zı ğ 43 K üt ah ya 70 K ar am an 51 N iğ de 08 A rtv in 30 H ak ka ri 45 M an is a 58 S iv as 28 G ire su n 44 M al at ya 48 M uğ la 66 Y oz ga t 29 G üm üş ha ne 49 M uş 64 U şa k 68 A ks ar ay 52 O rd u 62 T un ce li 71 K ırı kk al e 53 R iz e 65 V an 61 T ra bz on R EG IO N S A N D P R O VI N C ES 01 W ES T 02 S O U TH 03 C EN TR A L 04 N O R TH 05 E A ST 09 A yd ın 01 A da na 03 A fy on 60 T ok at 08 A rtv in 02 A dı ya m an 62 T un ce li 10 B al ık es ir 07 A nt al ya 05 A m as ya 64 U şa k 28 G ire su n 04 A ğr ı 63 Ş an lıu rfa 16 B ur sa 15 B ur du r 06 A nk ar a 66 Y oz ga t 29 G üm üş ha ne 12 B in gö l 65 V an 17 Ç an ak ka le 31 H at ay 11 B ile ci k 68 A ks ar ay 37 K as ta m on u 13 B itl is 69 B ay bu rt 20 D en iz li 32 Is pa rta 14 B ol u 70 K ar am an 52 O rd u 21 D iy ar ba kı r 72 B at m an 22 E di rn e 33 İç el 18 Ç an kı rı 71 K ırı kk al e 53 R iz e 23 E la zı ğ 73 Ş ırn ak 34 İs ta nb ul 46 K .M ar aş 19 Ç or um 81 D üz ce 55 S am su n 24 E rz in ca n 75 A rd ah an 35 İz m ir 80 O sm an iy e 26 E sk iş eh ir 57 S in op 25 E rz ur um 76 Iğ dı r 39 K ırk la re li 38 K ay se ri 61 T ra bz on 27 G az ia nt ep 79 K ili s 41 K oc ae li 40 K ırş eh ir 67 Z on gu ld ak 30 H ak ka ri 45 M an is a 42 K on ya 74 B ar tın 36 K ar s 48 M uğ la 43 K üt ah ya 78 K ar ab ük 44 M al at ya 54 S ak ar ya 50 N ev şe hi r 47 M ar di n 59 T ek ird ağ 51 N iğ de 49 M uş 77 Y al ov a 58 S iv as 56 S iir t Introduction | 1 INTRODUCTION 1 Sabahat Tezcan 1.1 Geography Turkey occupies a surface area of 774,815 square kilometers. 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 in the Thrace and Syria, Iraq, Iran, Georgia, Armenia, and Nahcivan (Azerbaijan) in the south and east Anatolia that is also called Asia Minor. The shape of the country resembles a rectangle, stretching in the east- west direction for approximately 1,565 kilometers and in the north-south direction for nearly 650 kilometers. 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 around 8,333 kilometers. The Anatolian peninsula lies on an elevated steppe-like and semi-arid central plateau surrounded by mountains on all sides, except the west. The Taurus Mountains in the south and the Northern Anatolia Mountains in the north stretch parallel to the coastline, meeting in the eastern part of the country. The average altitude of the country is around 1,130 meters above sea level. However, there are vast differences in altitude among the regions, ranging from an average of 500 meters in the west to 2,000 meters in the east Anatolia. The climate is characterized by variations of temperature and rainfall, depending on topography of the country. The average rainfall is 500 millimeters; however, it ranges from 2,000 millimeters in Rize, a province on the Eastern Black Sea coast, to less than 300 millimeters in some parts of Central Anatolia. The typical climatic conditions of Turkey include dry, hot summers and cold, rainy, snowy winters especially in the central and eastern regions. In summer, temperatures do not display large variations 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 Anatolia was dominated by the Seljuqs for almost two centuries (1055-1243) and afterwards she became the core of the Ottoman Empire, which ruled also in the Europe, Middle East and Africa for almost 6 centuries. At the end of The First World War, the Ottoman Empire demolished and immediately an effort to create a new state from the ruins of an Empire began throughout the country. The Turkish resistance movements were transformed into a complete war of independence when Mustafa Kemal landed at Samsun on 19 May 1919. The Turkish forces achieved success under very difficult conditions. The Lausanne Treaty, signed on 24 July 1923, recognized the creation of a new Turkish State with 2 | Introduction virtually the same borders as those of the National Pact of 1920 and guaranteed her complete independence. The Republic was proclaimed on 29 October 1923 in order to give the state a democratic form in the contemporary sense. Subsequently, the country’s present borders were established following the annexing of Hatay, a province on the southern border, in 1939. The founding of the Republic signified radical shifts from the previous social order as a succession of social and economic reforms. The wearing of the turban and fez that were symbols of the former order were banned and the "hat" became the official headgear (25 November 1925); the international hour and calendar systems were adopted (26 November 1925); the dervish lodges and tombs and the titles of tariqahs (sects) were abolished (25 November 1925); a modern Turkish Civil Code was introduced (17 February 1926) to replace the old civil code and the Shariah Laws which were the foundation stones of Ottoman law; the Latin alphabet was adopted instead of Arabic script (1 November 1928). The schools where mostly religion-related instruction was given were closed, and a program of compulsory education was set up which aimed at applying contemporary teaching methods. An amendment made to the Constitution in 1928 removed the clause which had stated that “the religion of the state is Islam”. A new clause was put in the Constitution in 1937 stating that Turkey is a secular state. The Surname Law was adopted on 21 June 1934. Mustafa Kemal, the founder of the new Turkish State and Republic, was given the surname of "Atatürk" (Father of the Turks). In short, the direction of change, led by Atatürk, was one away from a religious, oriental Empire to a modern, contemporary and secular Republic. Turkey did not become involved to the Second World War at the beginning but when the war was about to end, Turkey sided with the USA, Britain and the Soviet Union and declared war against Germany and Japan. However, Turkey did not take part actively in the war. Turkey signed the United Nations communiqué dated 24 January 1945. Turkey, which was officially invited to the San Francisco Conference on 5 March 1945, was among the founding members of the United Nations. From the foundation of the Turkish Republic to 1950, the country was governed by one party system. In the mid and late 1940s, new political parties formed. 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 democratic system until today, and this makes it unique among other countries where Islam has prominence. With the foundation of the Republic, Turkey turned her face to the ‘Western world’, as establishing close relations with European countries and 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. Since 2000, Turkey has achieved a noteworthy achievement in introducing new social, economic and political reforms within the context of the harmonization process with EU that was initiated with the Helsinki Summit of 1999 (State Planning Organization 2003). Turkey also maintains Introduction | 3 close relations with the countries of the Middle East, stemming from deep-rooted cultural and historical links. 1.3 Administrative Divisions and Political Organization Since the foundation of the Republic, the Turkish administrative structure has been shaped by three Constitutions (1924, 1961, and 1982). These three constitutions 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, namely legislative, administrative and judicial. 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 81 provinces. These are further subdivided into districts (ilçe), subdivisions (bucak), and villages (köy). The head of the province is the governor, who is appointed by the council of ministers and approved by the president of the republic 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 activities 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, elected by the municipal electoral body for a term of five years, administer local government at the municipality level. 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 within the boundaries of the municipality. Educational and health services are mainly provided by the central government, but municipalities also provide health services for those who are at lower economic and social strata. 1.4 Social and Cultural Features Turkey varies in social and cultural structure, with ‘modern’ and ‘traditional’ life styles co-existing simultaneously within the society. For the inhabitants of metropolitan areas daily life is similar to the Western countries. On the other hand, people living in outskirts of urban areas and rural settlements are relatively conservative and traditional. Family ties are still strong and influential in the formation of values, attitudes, aspirations, and goals. Although laws are considered to be quite liberal on gender equality, patriarchal ideology characterizes the social life in many ways. 4 | Introduction The citizens of Turkey are predominantly Muslim. About 98 percent of the population belongs to Muslim religion, with the Sunnis forming the overwhelming majority. The rich and complex culture of the Turkish society pertains to its ethnic structure. Since the time of Ottoman Empire; Turks predominate ethnically but, in addition, there are Kurdish, Arabic, Circassian, Georgian, Greek, Armenian, and Jewish communities. 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 the 2000 census figures, the female and male literacy rates for the population age 6 and over were 81 and 94 percent, respectively (State Institute of Statistics 2003). Educational attainment has also increased dramatically. The gross primary education enrolment ratio is 96 percent; 100 percent for males and 93 for females (State Institute of Statistics 2004). 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 After the foundation of the Turkish Republic, various economic development strategies were adopted. In the early years of the Republic, the Turkish economy was very weak since a bankrupt country was inherited from the Ottoman Empire. 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 liberal policies were implemented; the government promoted the development of industry through private enterprise, encouraged and assisted by favorable legislation and the introduction of credit facilities. These liberal policies continued until 1929, and moderate improvements were realized in the mechanization of agriculture. In the following decade, the state, under the so-called étatiste system, assumed the role of entrepreneur, owning and developing large sectors of agriculture, industry, mining, commerce and public works. The origins of modern industrialization in Turkey can be traced to the era of the 1930s. Although the beginnings of the industrialization 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, 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 infrastructural development, and the encouragement of foreign capital. Introduction | 5 A series of Five-Year Development Plans were prepared beginning in the 1960s. The first of these plans became operative in 1963. A basic objective was to replace the era of unplanned and uncontrolled expansion during the 1950s. Before 1980, Turkey followed an economic policy based on the substitution of imports, and instead of importing it was aimed to manufacture those goods in the country to meet domestic demand. Newly established industrial branches were protected for long periods of time by customs tariffs and other taxes. In the 1980s, governments followed a strategy of renewing economic growth based on an export-oriented strategy. In this way, substantial economic reforms were prepared and applied beginning in January 1980. Privatization implementations were started in the country in 1984. 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 étatiste phases are not only the nature of the trade regime and the attitude toward foreign direct investment, but also the mode of state intervention in the economy. Respectable rates of economic growth were achieved during the 1980s; however, in recent 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 globalization and integration into the European Union gained speed. During the 1990s, privatization also gained importance as a solution to economic problems. An autonomous committee was founded in order to regulate privatization. Some of the state enterprises have been privatized within the frame of this program, and further privatization is expected. Turkey is nearly self-sufficient country in terms of its agricultural production. Wheat, barley, sugar beets, potatoes, leguminous plants and rice are grown, principally for domestic consumption, and cotton, tobacco, citrus, grapes, fig, hazelnuts, and pistachios are also grown for export. 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 textiles, steel, cement, fertilizers, automotive and electrical household goods. Machinery, chemicals and some metals are imported mainly from the OECD countries. Turkey is a middle-income country at the beginning of 2000s. From 1998 onwards, Turkish authorities have made repeated affords to stabilize the economy. However, inherited economic instabilities; persistently high inflation, the systemic weakness of the financial sector and external shocks such as Russian crisis in 1998 and the earthquakes in 1999, hampered attempts to stabilize the economy. As a result, economic growth during 1997–2001 was very unstable, with periods of overheating and two sharp recessions. The financial crises in 2000 and 2001 contributed to a further deterioration in the public finance situation. Since 2001, key structural reforms have been adopted, that are intended to produce future macroeconomic stabilization within the context of the harmonization process with EU. Despite some recent progress, reducing inflation pressure, increasing export revenues, 6 | Introduction reducing unemployment problem and addressing insufficient capital for new investments remain key issues (State Planning Organization 2003; Ministry of Foreign Affairs 2004). 1.6 Regional Divisions The diverse geographical, climatic, cultural, social, and economic characteristics of different parts of the country are 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 within 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 socio-economically advanced region of the country. The region includes both İstanbul, (until 1923 the capital of the Ottoman Empire), which is Turkey's largest city, and the country's manufacturing, commercial and cultural centre, and İzmir, the country's third largest city. The coastal provinces within the West region form a relatively urbanized, fast-growing area. The Aegean coast is also a major agricultural area, where cotton, and fruits mostly grapes and fig are cultivated on the fertile plains. 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 region and the region contributes most of the gross domestic product of the country. The South includes highly fertile plains and some rapidly growing industrial centers. Adana, Mersin, and Antalya are the new metropolises located in this region. Steep mountains cut off the semitropical coastal plains from the Anatolian highlands to the north. Hot, dry summers and mild, wet winters describe the climatic conditions of the region. Cultivation of cotton, sugar beets and citrus provide high incomes and export earnings; tourism centers in Antalya provide almost one–third of tourism revenue. The South region has witnessed an industrial boom and an inflow of migrants, especially from the East and Southeastern provinces in the recent decades. The Central region is a dry grazing area and includes Ankara, the capital and second largest city. Industrial production in the region is rising modestly, as minor city centers develop. Industrial production in the region specializes in cereal and related processed foods, furniture and marble. Given the dry, temperate climate, fruit tree cultivation and sheep and cattle rising are also common. The North region has a fertile coastal strip, but in most places it is only a few kilometers wide; the coastal region is relatively isolated from the inner parts of the region and the rest of the country by mountainous terrain. The region specializes in growing small-scale, labor-intensive crops like hazelnuts, tobacco and tea. The region receives large quantities of rainfall throughout the year. Zonguldak, a western province, has extensive coal mine reserves and is a centre for coal mining and the steel industry. The region has a great deal of tourism potential that has been improving recently. Introduction | 7 The East region is considered as the least developed part of the 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 Southeast has improved in the recent years. Atatürk Dam was built (1983–1992) and Urfa irrigation channels were constructed and water was provided to arid and semi-arid lands, leading 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. A substantial number of villages and adjacent arable lands have been abandoned because of terrorist movements in last 20 years especially in East and Southeast Anatolia. In addition to this, large-scale development projects in the frame of Southeast Anatolia Project, natural disasters, or improved settlement policies have also led to significant migration both within and outside of the region in the last two decades. In response to these trends, the government initiated “Return to Villages and Rehabilitation Project” (RVRP) directed at this population. The main purposes of the RVRP, which covers the 14 provinces in the East and Southeast Anatolia, are to settle those who want to return to their villages on or around the lands of their former villages or on other suitable places, establish the necessary social and economic infrastructure, provide sustainable living conditions in these settlements, re- establish and vitalize the interrupted rural life, form a more balanced settlement design in the rural areas, and achieve a more rational distribution of public investments and services (State Planning Organization 2003). 1.7 Population In 1927, Turkey's population was 13.6 million according to the first national census, which was conducted four years after the establishment of the Republic. Beginning with the 1935 census, subsequent population censuses were undertaken regularly at 5-year intervals until 1990. After 1990, it was decided that population censuses would be carried out in years ending with 0 by a law. The latest, fourteenth, Population Census which was carried out on 22nd October 2000, put the population of Turkey at 67.4 million (State Institute of Statistics 2003). Turkey is among the 20 most populous countries of the world, and it is the most populous country of the Middle East and the second populous country of the Europe after Germany. According to projections, her population currently is around 71 million (Population Reference Bureau 2004). The population of Turkey continuously increased in 1927–2000 period. The annual population growth rate reached its highest value (29 per thousand) in the 1955–1960 period. The latest intercensal estimate of the population growth rate was 18 per thousand for the 1990–2000 period. According to the projections of the State Institute of Statistics (SIS), the population of Turkey is expected to reach 76 million in the year 2010 and 88 million in 2025. The total population is expected to be stabilized around mid 21st century between 95 and 98 million (State Institute of Statistics 1995). 8 | Introduction Turkey has a young population structure as a result of the high fertility and growth rates of the recent past. One-third of the population is under 15 years of age, whilst the proportion 65+ comprises only 6 percent according to 2000 national census results. However, today’s prevailing demographic forces of the population are altering the age structure in new ways. First of all, 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 late 1990s indicate it has nearly halved to 2.6 children. The crude birth rate was estimated at 22 per thousand in the early 2000s. As a result, the median age of the population, which averaged around 20 years between 1940 and 1960 in Turkey, has increased continuously since 1970, reaching 24 years for male and 25 years for female population in 2000. There have been significant changes in the growth rates by age groups. The growth rates for young age groups have decreased whereas the population of older age groups has increased faster than the average for Turkey. It is expected that increase in the population size of 15–64 and 65+ will continue also in the next years while population size of youth will nearly stabilize (State Institute of Statistics 2003). There is lack of accurate, complete and continuous information on mortality in Turkey, particularly adult mortality. The information is available mainly for deaths in town and city centers and these data are also incomplete. According to reported causes of deaths, the main causes of death in order of importance are cardio–vascular diseases (46 percent), all malignancies (15 percent) and all accidents (4 percent). In contrast to adult mortality, data on child mortality have been available for a relatively long period from a series of fertility surveys. The infant mortality rate in the late 1950s was around 200 per thousand live births. It declined to about 130 during the mid-1970s and to an estimated 42 during the late 1990s. Likewise, crude death rates have also declined from around 30 per thousand in the 1940s to 7 per thousand in 1990s. The latest estimates put life expectancy in Turkey at 66 years for males and 71 for females (State Institute of Statistics 2004). Marriage, predominantly civil, is widely practiced in Turkey. Religious marriages also account for a significant proportion of the marriages; however, the main custom is to have a civil as well as a religious ceremony. The universality of marriage in Turkey is observed in the low proportions never married. According to the 2000 Population Census, in the age group 45-49 which marks the end of the reproductive ages, only two percent of females had 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. The population of Turkey has undergone an intensive process of urbanization, especially from the 1950s onwards. The share of the population living in cities, which was 25 percent in 1950, climbed to 65 percent in 2000. The rate of urbanization has been approximately 33 per thousand during the 1990-2000 period. The rapid urbanization has inevitably caused problems in the provision of services and the emergence of large areas of squatter housing in unplanned settlements around metropolitan cities. Social problems related to the adaptation to city life and culture also are evident. Turkey has had a long history of external migration. Throughout the 1960s and 1970s, the migrant flow was mainly directed to Western European countries, principally Germany. Introduction | 9 During the 1980s, however, it became more oriented towards the oil-producing countries of the Middle East. In the past two decades, the political turmoil in that region and changes in policies and practices governing the labor force in the European Union have continued to influence emigration patterns. At the same time, due to political conditions in neighboring countries, Turkey has found herself subjected to waves of asylum seekers from the Balkans, Middle East countries, and also from distant Asian and African countries (International Organization for Migration 1996). 1.8 Population and Family Planning Policies and Programs In Turkey, policies related to population have been formulated since the establishment of the Republic in 1923. During the early years of the Republic, there was a perceived need to increase fertility, since the country had suffered from heavy human losses during the First World War and the War of Independence. The defense needs of the country and the shortage of manpower, as well as high infant and child mortality rates, led Turkey to continue to follow a pronatalist population policy until the late 1950s. A number of laws directly or indirectly encouraging population growth were passed during the period. These laws included monetary awards to women with more than 5 children, tax reduction incentives, prohibitions on the advertisement, import and sale of contraceptives (except for health reasons), and prohibition of abortions on social grounds. The high population growth rates prevailing in the 1950s which led to increased numbers of illegal abortions and, as a consequence, to high maternal mortality, 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 Organization and the Ministry of Health pioneered the policy change, and the first Population Planning Law was enacted in 1965. The law mandated the Ministry of Health to have responsibility for implementing the new family planning policy. The policy allowed the importation of modern contraceptives methods, provided services at state health institutions free of charge and supported health education for couples. In addition, the State Planning Organization incorporated the notion of population planning in the First Five-Year Development Plan. In 1983, a more liberal and comprehensive Population Planning Law was passed. The new law legalized abortions (up to the tenth week of pregnancy) and voluntary surgical contraception on social and economical grounds. It also permitted the trained auxiliary health personnel to insert IUDs and included other measures to improve family planning services and mother and child health. The latest Five Year Development Plan of the State Planning Organization states that population policy seeks to reach a population structure which is in harmony with the balanced and sustainable development targets of the society. Thus, the strengthening of qualitative aspects of population including increased education and improved health levels and a reduction in unbalanced development and inequalities among regions are primary objectives of population policy (State Planning Organization 2001). 10 | Introduction 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, high infant, child and maternal mortality rates, the demand for family planning services, and the limited prenatal and postnatal care. A number of programs to improve services have been implemented since 1985, 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 immunization, early diagnosis and prompt treatment of childhood diarrheal diseases, acute respiratory infections, promotion of breastfeeding and growth monitoring, healthy and balanced nutrition, reproductive health, and antenatal and delivery care, and safe motherhood. IEC (Information, Education, and Communication) programs to promote the mother and child health and family planning activities are also being widely implemented. 1.10 Health Care System in Turkey The Ministry of Health is officially responsible for designing and implementing health policies and delivering health-care services nationwide. Besides the Ministry of Health, other public sector institutions and non-governmental and private organizations contribute to providing mostly curative 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 Education) 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 as well as curative services. The present network of Health Centers 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 have health centers or health houses, and sites were located so as to provide easy access to other villages. The simplest element of the socialized health services is the Health House, which serves a population of 2,500-3,000 and is staffed by a midwife. The Health Center serves a population of 5,000-10,000 and is staffed by a team consisting of a physician(s), a nurse(s), a health officer, midwives, an environmental health technician, medical secretary and a driver. Health Centers mainly offer integrated, polyvalent primary health-care services. Mother and Child Health and Family Planning Centers and Tuberculosis Dispensaries also offer primary preventive health services. Introduction | 11 This network of health facilities is responsible for delivering primary health care services, maternal and child health, family planning, and public health education services. These health facilities are also the main sources of the health information system. 1.11 Objectives and Organization of the Survey 1.11.1 Objectives The 2003 Turkish Demographic and Health Survey (TDHS–2003) is the latest in a series of national-level population and health surveys that have been conducted by the Hacettepe University Institute of Population Studies (HUIPS), in the last four decades. The primary objective of the TDHS-2003 is to provide data on socioeconomic characteristics of households and women, fertility, mortality, marriage patterns, family planning, maternal and child health, nutritional status of women and children, and reproductive health. The survey obtained detailed information on these issues from a sample of ever-married women in the reproductive ages (15-49). The TDHS-2003 was designed to produce information in the field of demography and health that to a large extent can not be obtained from other sources. Specifically, the objectives of the TDHS-2003 included: • Collecting data at the national level that allows the calculation of demographic rates, particularly fertility and childhood mortality rates; • Obtaining information on direct and indirect factors that determine levels and trends in fertility and childhood mortality; • Measuring the level of contraceptive knowledge and practice by method, region, and urban-rural residence; • Collecting data relative to mother and child health, including immunizations, prevalence and treatment of acute respiratory tract infections among children under five, antenatal care, assistance at delivery, and breastfeeding; • Measuring the nutritional status of children under five and of their mothers; and • Collecting data at the national level on elderly welfare, knowledge of sexually transmitted diseases (STDs) and AIDS, and usage of iodide salt. The TDHS-2003 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. Another important purpose of the TDHS- 2003 is to sustain the flow of information for the interested organizations in Turkey and abroad on the Turkish population structure in the absence of reliable and sufficient vital registration system. 12 | Introduction 1.11.2 Administration and Funding of the Survey The TDHS-2003 was implemented by HUIPS, in collaboration with the General Directorate of Mother and Child Health and Family Planning of the Ministry of Health. HUIPS began preparations to carry out the survey as far back as 2001, and the fieldwork of the survey was conducted between December 2003 and May 2004. Financial support for the TDHS-2003 was mainly provided through the national budget as a three-year advanced project in the investment program of the State Planning Organization. In this respect, the TDHS-2003 is significantly different from the previous demographic and health surveys carried out by the Institute which were all conducted through international sources of funding. Moreover, the TDHS-2003 was supported for the first time as a project in the frame of the European Union “Turkey Reproductive Health Program”, implemented by the General Directorate of Mother and Child Health and Family Planning of the Ministry of Health. A steering committee consisting of the academic staff of HUIPS and representatives of the General Directorate of Mother and Child Health and Family Planning of the Ministry of Health, the State Planning Organization and the State Institute of Statistics participated in all phases of the project. The persons involved in the various activities of the TDHS–2003 are listed in Appendix A. 1.11.3 Questionnaires Two main types of questionnaires were used in the TDHS-2003: the Household Questionnaire and the Individual Questionnaire for ever-married women of reproductive ages. The contents of the questionnaires were based on the International MEASURE/DHS+ survey project model questionnaires and on the questionnaires that had been employed in previous Turkish population and health surveys. In developing the questionnaire, close attention was paid to obtaining the data needed for program planning in Turkey as specified during consultations with population and health agencies. Additionally input was obtained from other institutions studying on demographic and health issues. Ensuring the comparability of the TDHS–2003 findings with previous demographic surveys, particularly with TDHS–1993 and TDHS–1998, was an important goal during questionnaire development. A pretest of questionnaire was conducted in July 2003 and based on the pretest results, some minor modifications were made to the questionnaires. The Household Questionnaire was used to enumerate all members of and visitors1 to the selected households and to collect information relating to the socio-economic level of the households. In the first part of the household questionnaire, basic information was collected on the age, sex, educational attainment, marital status, working status and relationship to the head of household of each person listed as a household member or visitor. The objective of the first 1 Persons who were not usual household members but who were present in that household on the night before the interview were identified as “visitors” and included in the household roster in order to obtain de facto survey population. Introduction | 13 part of the Household Questionnaire was to obtain basic socio-economic information for Turkish households as well as to identify women who were eligible for the Individual Questionnaire. Some additional information on never-married women in 15–49 ages listed in the household schedule was provided at the end of this part. The second part of the household questionnaire was devoted to collecting data on welfare of the elderly, if any, in the households. In this part, there are questions on the income, health insurance and physical capabilities (i.e. ability to carry on daily activities for all persons age 60 and over living in the household. In the third part, questions were included on the dwelling unit and on the ownership of a variety of consumer goods. Also in this part, İstanbul Metropolitan Household Module was included which covers questions about tenure, and the availability of electricity, piped-water, and natural gas in the households located in the urban places of İstanbul metropolitan area. In the final part of the Household Questionnaire questions were included about the storage of the salt used for cooking at home. Salt-related questions were asked in the half of the sampled clusters, and salt iodization tests were applied in the interviewed households in these clusters. The Individual Questionnaire covered the following information: • Background characteristics • Reproductive history • Marriage • Knowledge and use of contraceptive methods • Other information relating to contraception • Abortions and causes • Maternal health care and breastfeeding • Immunization and acute respiratory infections • Fertility preferences • Husband’s background characteristics • Women’s work and status • Knowledge of sexually transmitted diseases and AIDS • Maternal and child anthropometry The calendar module in the Individual Questionnaire was used to record on a monthly basis fertility, contraceptive use and marriage events for six and a half years beginning from January 1998 up to the survey month. English versions of the two questionnaires can be seen in Appendix E. 1.11.4 Sample The sample design and sample size of the TDHS-2003 makes it possible to perform analyses for Turkey as a whole, for urban and rural areas and for the five demographic regions of the country (West, South, Central, North and East). The TDHS-2003 sample is of sufficiently size to allow for analysis on some of the survey topics at the level of the 12 geographical 14 | Introduction regions (NUTS 1) which were adopted at the second half of the year 2002 within the context of Turkey’s move to join the European Union. Among these 12 regions, İstanbul and the Southeastern Anatolian Project regions (GAP in Turkish initials), due to their special situations were oversampled. Most results in this report are presented for five demographic regions as used in the previous surveys and for İstanbul and GAP region2. In addition for a number of indicators results are presented in detail for the 12 geographical regions, whenever the numbers of observations are sufficient (see Appendix B for detailed information). In the selection of the TDHS-2003 sample, a weighted, multi-stage, stratified cluster sampling approach was used. The distribution of the target sample of the survey was based on the results of the 2000 General Population Census. Sample selection for the TDHS-2003 was undertaken in three stages. The sampling units at the first stage were settlements. The frame for the selection of primary sampling units was prepared using the results of the 2000 General Population Census. In the sampling frame, settlements were divided into two groups; one including those settlements with populations more than 10,000 as “urban”, and the other, including settlements less than 10,000 as “rural”. In the survey design, the selection of the settlements in each cluster was done with probability proportional to their population size. For the second stage of sample selection, structure schedule data that was collected in the year 2000 for settlements with a municipality and updated in 2002 by the State Institute of Statistics was used. Using the updated household lists, a fixed number of households were selected in each cluster by systematic random sampling method (25 in clusters located in settlements over 10,000, 15 in those less than 10,000, and 12 in the İstanbul metropolitan clusters). All ever- married women at ages 15-49 who generally live in the selected households and/or were present in the household on the night before the interview were eligible for the Individual Questionnaire. A more technical and detailed description of the TDHS-2003 sample design, selection and implementation is presented in Appendix B. 1.11.5 Fieldwork and Data Processing The TDHS-2003 data collection was carried out by 14 teams3. Each team was consisted of 3-5 female interviewers, one male measurer, one field editor and a team supervisor. The Institute’s academic staff had visited teams in the field as regional coordinators during the survey. A three-week training course was given to the field staff in November 2003. The main fieldwork began in the first week of December 2003 and completed in the middle of May 2004. The fieldwork was planned to take into consideration the seasonal conditions in Turkey. 2 İstanbul province and Southeast Anatolia (GAP) region constitute the two regions of NUTS 1 geographical regions. 3 The fieldwork of the TDHS-2003 was started with 14 teams in December 2003. In order to finalize the fieldwork in the remaining provinces, 19 new teams were formed gradually among the teams that completed their work and returned. Introduction | 15 Therefore, in the first months the fieldwork was concentrated in the provinces located in the West, the South and the Central Anatolia regions where winter conditions would have a minimum affect on the survey. The North and the Eastern Anatolia provinces were included to the fieldwork later as weather conditions improved. The fieldwork was finalized without any interruptions in the planned period. The completed questionnaires in the field were returned to the Institute of Population Studies in Ankara for data processing. The office editing staff checked all questionnaires returned from the field. Those questions which had not been pre-coded and questions with open-ended answers were coded by the office team. After this, the data entry and editing were done using microcomputers and CSPro (Census and Survey Processing System) software. During data entry process, full verification was reached by entering each questionnaire to the computers twice by different data editors. The office editing and data processing activities began in January 2004 (three weeks after the beginning of the fieldwork) and were completed at the end of May 2004. 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, 13,049 households were selected for the TDHS-2003. At the time of listing phase of the survey, 11,659 households were considered occupied and, thus, available for interview. Of the 11,659 occupied households, 93 percent (10,836 households) were successfully interviewed. The main reasons the field teams were unable to interview some households were because some dwelling units that had been listed were found to be vacant at the time of the interview or the household was away for an extended period. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates by urban-rural residence, Turkey 2003 Result Urban Rural Total Household interviews Dwellings sampled 9,754 3,295 13,049 Households found 8,718 2,941 11,659 Households interviewed 7,956 2,880 10,836 Household response rate 91.3 97.9 92.9 Individual interviews Eligible women 6,259 2,188 8,447 Eligible women interviewed 5,976 2,099 8,075 Eligible women response rate 95.5 95.9 95.6 In the interviewed 10,836 households, 8,447 women were identified as eligible for the individual interview, i.e. they were ever-married, in reproductive ages (15-49) and present in the household on the night before the interview. Interviews were successfully completed with 8,075 of these women (95.6 percent). Among the eligible women not interviewed in the survey, the principal reason for non-response was the failure to find the women at home after repeated visits to the household. 16 | Introduction A more complete description of the fieldwork, coverage of the sample, and data processing is presented in Appendix B. Household Population and Housing Characteristics | 17 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 İsmet Koç and Attila Hancıoğlu The objective of this chapter is to provide a demographic and socioeconomic profile of the TDHS-2003 sample and a descriptive assessment of the environment in which women and children live. This is accomplished by examining the general characteristics of the households in the sample. Information is presented on the age, sex, and education of the household population, as well as on housing facilities and household possessions. The profile of the TDHS-2003 households provided in this chapter will help in understanding the results presented in the following chapters. In addition, it may provide useful input for social and economic development planning. 2.1 Characteristics of the Household Population The questionnaire for the TDHS-2003 included two questions distinguishing between the de jure population (persons who usually live in selected household) and the de facto population (persons who spent the night before the interview in the household). The differences between these populations are small. However, since past surveys and censuses were based on de facto populations, and since the sampling probabilities were based on de facto population information, tabulations for the household data presented in this chapter are based on the de facto definition, unless otherwise stated. A household was defined as a person or group of persons living together and sharing a common source of food. 2.1.1 Age and Sex Composition Table 2.1 presents the percent distribution of the de facto population by age, according to urban-rural residence and sex. The table shows the effects of past demographic trends on the structure of the Turkish population and indicates the context in which a variety of demographic processes are operating. The total de facto population in the selected households was 42,851 persons. In general, the survey results show that females outnumber males in Turkey (51 and 49 percent respectively). The proportion of females is slightly higher in rural areas (52 and 48 percent). The information on sex and age distribution is used to construct a population pyramid describing the TDHS-2003 household population (Figure 2.1). The pyramid has a wide base, with a large concentration (29 percent) of the population under 15 years of age. This pattern is typical of countries that have experienced relatively high fertility in the recent past. The effect of recent fertility declines is evident in the fact that the proportions of children under age 5 and age 5 to 9 are smaller than the proportion age 10 to 14. The proportion under age 15 is greater in the rural population than in the urban population (Table 2.1). The differences in the urban-rural age distributions reflect the lower recent fertility in urban areas compared with rural areas. 18 | Household Population and Housing Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Turkey 2003 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 9.8 8.5 9.1 10.4 9.5 9.9 10.0 8.8 9.4 5-9 9.7 9.4 9.5 11.1 9.9 10.5 10.1 9.5 9.8 10-14 9.6 9.5 9.6 11.4 9.9 10.6 10.2 9.7 9.9 15-19 10.4 9.3 9.8 9.0 10.1 9.6 10.0 9.6 9.8 20-24 8.6 9.9 9.3 7.1 9.3 8.3 8.1 9.7 8.9 25-29 8.6 9.5 9.0 6.2 6.5 6.4 7.8 8.5 8.2 30-34 8.2 7.9 8.0 6.1 6.7 6.4 7.5 7.5 7.5 35-39 7.0 7.1 7.0 5.8 6.4 6.1 6.6 6.9 6.7 40-44 6.6 6.8 6.7 5.9 5.5 5.7 6.4 6.4 6.4 45-49 5.8 5.4 5.6 5.1 4.7 4.9 5.6 5.2 5.4 50-54 4.5 4.9 4.7 4.4 4.8 4.6 4.5 4.9 4.7 55-59 3.5 3.1 3.3 4.3 4.0 4.2 3.8 3.4 3.6 60-64 2.3 2.6 2.5 3.5 3.4 3.5 2.7 2.9 2.8 65-69 1.9 2.4 2.2 3.2 3.4 3.3 2.3 2.8 2.5 70-74 1.7 1.7 1.7 2.8 2.8 2.8 2.0 2.1 2.1 75-79 1.0 1.1 1.0 2.1 1.8 1.9 1.4 1.3 1.3 80 + 0.6 0.9 0.8 1.5 1.2 1.3 0.9 1.0 1.0 Don't know/missing 0.1 0.0 0.0 0.1 0.0 0.1 0.1 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 14,314 14,894 29,208 6,528 7,116 13,644 20,842 22,010 42,851 Figure 2.1 Population Pyramid 6.0 4.0 2.0 0.0 2.0 4.0 6.0 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80+ Age Percent Male Female TDHS-2003 Household Population and Housing Characteristics | 19 The population age 65 and over accounts for 7 percent of the total population in Turkey. The share of elderly population is approximately 6 percent in urban areas, as opposed to over 9 percent in the rural areas. The percentage of elderly has risen to the highest proportion in the demographic history of Turkey. This may mainly be attributable to two factors: the rapid decline in fertility and increased life expectancy at all ages. Table 2.2 presents a comparison of the distribution of the household population by broad age groups for the last three demographic surveys and the last two censuses carried out in 1990 and 2003. The dependency ratio, defined as the ratio of the non-productive population (persons under age 15 and age 65 and over) to the population age 15-64, is calculated based on these figures. The dependency ratio, which was above 65 at the time of the 1990 Population Census, had declined to 56 at the time of the TDHS-2003. The decline reflects a significant decrease 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 24.7 years, 2.5 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. Table 2.2 Population by age from selected sources Percent distribution of the population by age group, selected sources, Turkey 1990-2003 Age group CP 1990 TDHS-1993 TDHS-1998 CP 2000 TDHS-2003 Less than 15 35.0 33.0 31.5 29.8 29.1 15-64 60.7 61.4 62.6 64.5 64.0 65 and + 4.3 5.5 5.9 5.7 6.9 Total 100.0 100.0 100.0 100.0 100.0 Median age 22.2 23.1 24.3 24.8 24.7 Dependency ratio 64.7 62.7 59.7 55.1 56.3 Sources: 1990 and 2000 Census of Population (CP), TDHS-1993, TDHS-1998 and TDHS-2003 2.1.2 Household Composition Table 2.3 presents the distribution of households in the TDHS-2003 sample by sex of the head of the household and by the number of household members. These characteristics are important because they are often associated with socioeconomic differences between households. For example, female-headed households frequently are poorer than households headed by males. In addition, the size and composition of the household affects the allocation of financial and other resources among household members, which in turn influences the overall well-being of these individuals. Household size is also associated with crowding in the dwelling, which can lead to unfavorable health conditions. Unlike earlier tables, Table 2.3 is based on de jure members, i.e. usual residents. The household head is female in 13 percent of households. Although there is little variation in the proportion of female-headed households by residence, female-headed households are more common in urban areas (13 percent) than in rural areas (11 percent). There are on average 4 persons per household. More than four in ten households have fewer than four members, while another quarter of the households have five members, and 20 | Household Population and Housing Characteristics one-third of households has six or more members. In general, rural households are larger than urban households. For example, less than five percent of urban households have eight or more members, compared with 11 percent of rural households. Household size varies from an average of 3.9 persons in the urban areas to 4.5 persons in rural areas. Table 2.3 Household composition Percent distribution of households by sex of head of household and by household size, according to urban-rural residence, Turkey 2003 Characteristic Urban Rural Total Sex of head of household Male 87.0 88.6 87.5 Female 13.0 11.4 12.5 Total 100.0 100.0 100.0 Number of usual members 0 0.3 0.4 0.3 1 6.3 6.3 6.3 2 16.5 17.3 16.8 3 21.8 13.7 19.4 4 26.3 19.3 24.2 5 14.5 15.0 14.7 6 6.8 10.6 7.9 7 3.4 6.1 4.2 8 1.9 3.8 2.4 9+ 2.2 7.5 3.8 Total 100.0 100.0 100.0 Number of households 7,643 3,193 10,836 Mean size 3.9 4.5 4.1 Note: The table is based on de jure members, i.e., usual residents. 2.2 Fosterhood and Orphanhood Foster children are children under 18 years of age who are not living with either of their biological parents. Orphaned children are children under 18 years of age who have lost one or both of their biological parents. To measure the prevalence of child fostering and orphanhood, four questions were asked in the Household Questionnaire on the survival and residence of the parents of children under 18 years of age. Information on children’s living arrangements and orphanhood is presented in Table 2.4. In Turkey, 92 percent of children under age 18 live with both parents. The proportion of children living with both parents decreases with increasing age. Children living in the North are somewhat less likely to live with both parents than children in other regions. Household Population and Housing Characteristics | 21 Table 2.4 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by children's living arrangements and survival status of parents, according to background characteristics, Turkey 2003 Living with mother but not father Living with father but not mother Not living with either parent Background characteristic Living with both parents Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Miss- ing Total Number of children Age <2 98.5 1.0 0.2 0.1 0.1 0.2 0.0 0.0 0.0 0.0 100.0 1,457 2-4 95.8 2.0 0.5 0.4 0.1 0.7 0.1 0.1 0.0 0.3 100.0 2,509 5-9 94.6 2.1 1.4 0.5 0.3 0.8 0.2 0.0 0.1 0.1 100.0 4,199 10-14 91.1 2.5 3.2 0.5 0.8 1.5 0.1 0.0 0.1 0.0 100.0 4,326 15-17 83.1 3.3 4.7 0.9 1.7 5.4 0.2 0.4 0.2 0.2 100.0 2,717 Sex Male 92.4 2.4 2.2 0.5 0.7 1.4 0.1 0.1 0.1 0.1 100.0 7,729 Female 91.8 2.3 2.3 0.5 0.6 2.1 0.2 0.1 0.1 0.1 100.0 7,478 Residence Urban 91.8 2.5 2.0 0.7 0.5 2.0 0.1 0.1 0.1 0.1 100.0 9,976 Rural 92.6 1.9 2.6 0.1 0.8 1.3 0.2 0.2 0.1 0.1 100.0 5,231 Region West 92.2 2.5 1.6 0.6 0.5 2.1 0.1 0.0 0.1 0.2 100.0 4,926 South 91.5 3.1 1.8 0.6 0.8 1.9 0.1 0.0 0.1 0.1 100.0 2,102 Central 91.8 2.9 2.4 0.5 0.4 1.6 0.1 0.0 0.2 0.1 100.0 3,066 North 90.5 1.8 2.1 0.5 1.1 3.1 0.5 0.2 0.1 0.1 100.0 1,076 East 93.0 1.4 3.1 0.3 0.8 1.0 0.1 0.3 0.1 0.0 100.0 4,038 NUTS 1 Region İstanbul 92.2 2.0 1.7 0.5 0.4 2.7 0.1 0.0 0.1 0.2 100.0 2,285 West Marmara 90.3 2.5 1.8 1.0 0.6 2.5 0.2 0.2 0.3 0.6 100.0 472 Aegean 91.7 3.2 2.0 0.7 0.4 1.7 0.0 0.0 0.0 0.3 100.0 1,607 East Marmara 93.5 2.2 1.8 0.6 0.8 0.9 0.2 0.0 0.0 0.0 100.0 1,071 West Anatolia 92.6 2.9 1.7 0.6 0.5 1.5 0.1 0.0 0.2 0.0 100.0 1,344 Mediterranean 91.5 3.1 1.8 0.6 0.8 1.9 0.1 0.0 0.1 0.1 100.0 2,102 Central Anatolia 90.8 3.3 3.1 0.4 0.7 1.4 0.1 0.1 0.2 0.0 100.0 854 West Black Sea 90.4 3.5 1.7 0.5 0.3 3.3 0.1 0.1 0.0 0.1 100.0 874 East Black Sea 91.3 0.7 2.3 0.4 1.6 2.4 0.9 0.2 0.2 0.0 100.0 560 Northeast Anatolia 91.9 2.2 4.2 0.3 0.3 0.8 0.0 0.3 0.0 0.0 100.0 689 Central East Anatolia 93.5 0.8 3.1 0.1 0.8 1.0 0.2 0.5 0.0 0.0 100.0 1,128 Southeast Anatolia 93.0 1.4 2.8 0.4 0.9 1.1 0.1 0.1 0.1 0.1 100.0 2,221 Total 92.1 2.3 2.2 0.5 0.6 1.8 0.1 0.1 0.1 0.1 100.0 15,207 Six percent of children live with only one parent–5 percent with their mothers and 1 percent with their fathers. Three percent of children live with only one parent because the other parent is dead. Foster children–children not living with either parent–account for only 2 percent of children under 18, and orphaned children–children who have lost one or both parents–account for 3 percent. The proportion of orphaned children at age 15-17 is approximately 7 percent. 2.3 Education of the Household Population The educational level of household members is among the most important characteristics of the household because it is associated with many phenomena including reproductive behavior, use of contraception, and the health of children. Results from 22 | Household Population and Housing Characteristics household interviews can be used to look at both educational attainment among household members and school attendance among children and young adults. 2.3.1 Educational Attainment of Household Members Primary education in Turkey starts at age 6 and continues for 8 years. Eight years of education is considered as basic education and has been compulsory since 1997. High school, which includes another three years of schooling, is not compulsory. Tables 2.5.1 and 2.5.2 present data on the educational level of the household population age 6 and over for males and females, respectively. The results confirm that there is a gap in educational attainment between males and females. Overall, about 77 percent of males in the TDHS-2003 households have completed at least first level primary school, compared with 61 percent of females. However, among the population with any schooling, over one-third of males as well as females have completed at least second level primary school. The median number of years of schooling for men is 4.8 which is about 0.5 year higher than the median level for women (4.3 years). An examination of the changes in educational indicators over successive cohorts indicates that there have been substantial increases over time in the educational attainment of both men and women. For example, the median number of years of schooling is 9 years for males age 20-24 years, compared with 4.9 years in the 40-44 age group. Women have experienced substantial improvements in education as well. As a result, the differentials in educational attainment between males and females have narrowed among younger cohorts. Urban residents are more likely to have attended school and to have remained in school for a longer period than rural residents. Gender differences in educational attainment are also less evident in rural than in urban areas. The median number of years of schooling is 4.5 years among rural men, compared with 4.0 years among rural women. The difference is much bigger in urban areas, where the median years of schooling are 5.4 and 4.5, respectively for men and women. Gender differences in the likelihood of attending school are greatest in the East, and least in the West. In the East, 85 percent of men have ever attended school, compared with about 61 percent of women. In the West, the gap is much smaller, with nearly 85 percent of women having had some education, compared with 95 percent of men. Household Population and Housing Characteristics | 23 Table 2.5.1 Educational attainment of household population: Males Percent distribution of the de facto male household population age six and over by highest level of education attended or completed, according to background characteristics, Turkey 2003 Background characteristic No education/ Primary incomplete First level primary Second level primary High school and higher Missing Total Number of males Median number of years Age 6-9 99.3 0.2 0.0 0.0 0.5 100.0 1,706 0.4 10-14 36.6 53.4 9.9 0.1 0.0 100.0 2,119 4.7 15-19 5.0 19.0 55.0 21.0 0.1 100.0 2,078 8.0 20-24 3.6 33.0 15.7 47.6 0.2 100.0 1,696 9.1 25-29 4.0 41.1 11.7 42.8 0.4 100.0 1,636 7.5 30-34 4.6 46.9 12.9 35.3 0.3 100.0 1,572 6.4 35-39 6.5 48.1 15.5 29.5 0.5 100.0 1,379 5.4 40-44 6.3 53.8 11.2 28.0 0.6 100.0 1,338 4.9 45-49 8.6 53.5 9.4 28.1 0.5 100.0 1,166 4.8 50-54 12.9 55.4 7.2 23.8 0.7 100.0 931 4.7 55-59 21.1 53.6 9.5 14.9 0.9 100.0 785 4.6 60-64 32.5 45.9 5.3 15.2 1.2 100.0 557 4.4 65+ 53.5 34.9 3.0 6.7 1.9 100.0 1,369 2.5 Residence Urban 19.8 36.3 15.4 28.1 0.4 100.0 12,638 5.4 Rural 30.5 45.6 13.2 10.1 0.7 100.0 5,713 4.5 Region West 18.8 42.3 13.9 24.5 0.4 100.0 7,221 4.9 South 24.6 40.2 15.5 19.0 0.8 100.0 2,376 4.8 Central 19.2 38.3 16.0 26.1 0.4 100.0 4,021 5.0 North 22.9 38.9 16.3 21.2 0.7 100.0 1,409 4.8 East 36.5 32.7 13.6 16.5 0.6 100.0 3,324 4.5 NUTS 1 Region İstanbul 17.6 40.1 15.1 26.6 0.6 100.0 3,244 5.1 West Marmara 20.0 45.5 13.9 19.8 0.9 100.0 752 4.8 Aegean 21.2 45.0 12.5 21.2 0.1 100.0 2,423 4.8 East Marmara 17.2 40.2 15.4 27.2 0.0 100.0 1,619 5.2 West Anatolia 17.3 36.4 15.4 30.7 0.2 100.0 1,696 5.7 Mediterranean 24.6 40.2 15.5 19.0 0.8 100.0 2,376 4.8 Central Anatolia 20.3 38.8 15.6 24.3 1.0 100.0 1,031 4.9 West Black Sea 22.7 40.6 16.5 19.5 0.6 100.0 1,173 4.8 East Black Sea 23.9 37.0 16.4 22.0 0.8 100.0 714 4.8 Northeast Anatolia 29.3 33.7 15.9 20.4 0.7 100.0 607 4.7 Central East Anatolia 35.7 30.6 13.5 19.6 0.6 100.0 962 4.6 Southeast Anatolia 39.4 33.6 12.9 13.5 0.5 100.0 1,755 4.4 Total 23.2 39.2 14.7 22.5 0.5 100.0 18,351 4.8 24 | Household Population and Housing Characteristics Table 2.5.2 Educational attainment of household population: Females Percent distribution of the de facto female household population age six and over by highest level of education attended or completed, according to background characteristics, Turkey 2003 Background characteristic No education/ Primary incomplete First level primary Second level primary High school and higher Missing Total Number of females Median number of years Age 6-9 99.6 0.1 0.0 0.0 0.3 100.0 1,691 0.4 10-14 38.5 51.5 9.9 0.0 0.1 100.0 2,126 4.6 15-19 14.9 28.7 41.6 14.8 0.0 100.0 2,103 7.4 20-24 12.3 43.5 9.7 34.5 0.0 100.0 2,137 4.9 25-29 13.2 48.3 7.4 31.1 0.0 100.0 1,876 4.8 30-34 18.0 55.0 7.3 19.7 0.0 100.0 1,647 4.6 35-39 22.6 54.4 6.4 16.5 0.1 100.0 1,508 4.5 40-44 30.0 48.9 5.1 15.9 0.1 100.0 1,408 4.4 45-49 33.9 49.3 4.7 12.1 0.0 100.0 1,135 4.3 50-54 54.5 32.3 3.3 9.6 0.3 100.0 1,070 2.5 55-59 66.2 24.9 2.3 6.0 0.6 100.0 743 0.0 60-64 68.3 23.5 1.9 5.3 0.9 100.0 636 0.0 65+ 82.6 12.7 1.5 2.4 0.0 100.0 1,576 0.0 Residence Urban 33.8 36.4 10.8 18.8 0.2 100.0 13,368 4.5 Rural 48.8 40.1 6.6 4.4 0.2 100.0 6,293 4.0 Region West 31.5 40.7 10.0 17.6 0.2 100.0 7,520 4.5 South 40.9 35.9 10.1 12.8 0.3 100.0 2,601 4.3 Central 31.8 42.0 10.9 15.3 0.0 100.0 4,431 4.5 North 38.2 38.5 9.8 13.1 0.3 100.0 1,531 4.3 East 60.2 26.6 6.1 6.9 0.2 100.0 3,579 1.8 NUTS 1 Region İstanbul 30.5 39.4 10.5 19.2 0.4 100.0 3,295 4.6 West Marmara 30.8 46.3 9.2 13.5 0.2 100.0 822 4.5 Aegean 32.1 42.7 9.1 16.1 0.0 100.0 2,610 4.5 East Marmara 32.4 41.1 10.9 15.4 0.2 100.0 1,652 4.5 West Anatolia 27.7 39.6 12.3 20.4 0.1 100.0 1,881 4.6 Mediterranean 40.9 35.9 10.1 12.8 0.3 100.0 2,601 4.3 Central Anatolia 38.1 40.3 9.5 12.1 0.0 100.0 1,157 4.3 West Black Sea 34.4 44.3 9.2 11.9 0.3 100.0 1,308 4.4 East Black Sea 43.1 32.2 10.6 13.9 0.2 100.0 756 4.2 Northeast Anatolia 52.4 30.7 7.5 9.2 0.2 100.0 667 3.2 Central East Anatolia 59.8 25.5 5.8 8.7 0.2 100.0 1,044 1.6 Southeast Anatolia 63.2 25.8 5.7 5.1 0.2 100.0 1,868 1.3 Total 38.6 37.6 9.5 14.2 0.2 100.0 19,661 4.3 Household Population and Housing Characteristics | 25 2.3.2 School Attendance Ratios The TDHS-2003 collected information on current school attendance for the population age 6-24 years. Figure 2.2 presents the percentage of the population in this age range that was attending school at the time of the survey. The comparatively low age-specific attendance rate for children age 6 reflects that some of these children had not had their sixth birthday at the time the school year started and thus were not eligible to attend school. Overall, the majority of children of both sexes age 15 and under were attending school. However, Figure 2.2 shows that school attendance rates are generally higher among boys than among girls. The gender gap in school attendance increases somewhat with age, particularly among the post-first level primary ages (i.e., 11-24 years). Table 2.6 provides net attendance ratios (NAR) and gross attendance ratios (GAR) by residence and region according to sex and school level. The NAR for primary school is the percentage of the primary school-age (6-13 years) population that is attending primary school. The NAR for high school is the percentage of the high school age (14-16 years) population that is attending high school. By definition, the NAR cannot exceed 100 percent. The GAR for primary school is the total number of primary school students of any age, expressed as the percentage of the official primary school age population. The GAR for high school is the total number of high school students up to age 24, expressed as the percentage of the official high school age population. If there are significant numbers of over-age and under-age students at a given level of schooling, the GAR can exceed 100 percent. Children are considered to be attending school currently if they attended at any point during the current school year. TDHS-2003 Figure 2.2 Age-Specific Attendance Rates 0 10 20 30 40 50 60 70 80 90 100 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age Percent Male Female 26 | Household Population and Housing Characteristics Table 2.6 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de jure household population by level of schooling and sex, according to background characteristics, Turkey 2003 Net attendance ratio Gross attendance ratio Background characteristic Male Female Total Male Female Total Gender Parity Index PRIMARY SCHOOL Residence Urban 91.5 89.2 90.3 100.4 94.3 97.3 0.94 Rural 88.8 82.8 85.9 100.4 88.0 94.5 0.88 Region West 93.9 93.5 93.7 102.8 98.0 100.3 0.95 South 91.7 90.0 90.8 99.3 94.8 97.1 0.95 Central 91.2 90.7 91.0 99.8 96.6 98.1 0.97 North 93.3 90.4 91.9 101.5 96.6 99.1 0.95 East 84.8 73.0 79.1 98.4 78.5 88.8 0.80 NUTS 1 Region İstanbul 94.6 92.3 93.4 102.3 96.9 99.4 0.95 West Marmara 94.7 91.7 93.1 103.7 95.2 99.2 0.92 Aegean 92.2 95.6 93.8 102.7 101.6 102.2 0.99 East Marmara 95.1 88.9 92.0 105.3 94.0 99.6 0.89 West Anatolia 91.2 91.2 91.2 100.3 94.4 97.2 0.94 Mediterranean 91.7 90.0 90.8 99.3 94.8 97.1 0.95 Central Anatolia 92.4 94.8 93.6 100.0 100.0 100.0 1.00 West Black Sea 90.6 92.0 91.3 98.5 102.1 100.3 1.04 East Black Sea 92.0 88.2 90.2 98.2 91.6 95.0 0.93 Northeast Anatolia 88.1 78.9 83.6 97.0 86.5 91.9 0.89 Central East Anatolia 81.6 73.3 77.6 101.4 79.1 90.6 0.78 Southeast Anatolia 85.4 70.9 78.5 97.3 75.7 87.0 0.78 Total 90.6 87.0 88.8 100.4 92.2 96.3 0.92 HIGH SCHOOL Residence Urban 60.9 57.1 59.0 89.9 76.6 83.4 0.85 Rural 38.3 28.1 33.3 62.6 37.9 50.4 0.61 Region West 56.7 56.2 56.5 83.8 76.4 80.4 0.91 South 56.2 47.0 51.5 85.5 63.8 74.4 0.75 Central 61.2 59.4 60.3 86.9 76.7 81.6 0.88 North 61.6 53.7 57.9 95.2 75.1 85.7 0.79 East 36.6 22.8 29.7 62.5 31.0 46.8 0.50 NUTS 1 Region İstanbul 58.6 57.4 58.1 86.7 73.7 80.5 0.85 West Marmara 60.9 60.5 60.7 86.7 85.8 86.3 0.99 Aegean 44.3 48.9 46.6 66.4 66.2 66.3 1.00 East Marmara 59.3 56.5 58.1 91.4 85.0 88.5 0.93 West Anatolia 70.5 69.8 70.1 91.8 85.0 88.2 0.93 Mediterranean 56.2 47.0 51.5 85.5 63.8 74.4 0.75 Central Anatolia 56.6 57.0 56.8 81.3 75.5 78.4 0.93 West Black Sea 63.1 46.0 54.1 100.2 62.7 80.5 0.63 East Black Sea 68.3 67.6 68.0 104.1 102.1 103.2 0.98 Northeast Anatolia 49.5 32.4 41.1 79.9 44.0 62.3 0.55 Central East Anatolia 35.6 23.0 29.3 66.1 31.0 48.6 0.47 Southeast Anatolia 32.8 19.5 26.1 54.3 26.6 40.4 0.49 Total 53.0 46.9 50.0 80.4 63.0 71.8 0.78 Household Population and Housing Characteristics | 27 Table 2.6 shows that 89 percent of primary school age children in Turkey are attending primary school. The NAR is higher in urban areas than in rural areas (90 and 86 percent, respectively), as is the GAR (97 and 95 percent, respectively). There is significant variation between the East and other regions: the NAR in the East is 79 percent while it is over 90 percent in all other regions. At the high school level, the NAR is 50 percent and the GAR is 72 percent. Regional disparities at the high school level are even more pronounced than at the primary school level: the NAR, for example, ranges from a low of 26 percent in Southeast Anatolia, to a high of 70 percent in West Anatolia. The Gender Parity Index (GPI) represents the ratio of the GAR for females to the GAR for males. It is presented for both the primary and high school levels and offers a summary measure of the extent to which there are gender differences in attendance rates. A GPI of less than 1 indicates that a smaller proportion of females than males attend school. The GPI for primary school is 0.92 and for high school is 0.78. Although there is little urban-rural differential at the primary school level, there is significant difference at the high school level. Once again, regional differentials are significant; the data indicate that girls residing in the eastern part of Turkey are particularly disadvantaged. Gender disparities by age in school attendance at any level are also shown in Figure 2.2. 2.3.3 Repetition and Dropout Rates The repetition rate is the percentage of students in a given grade the previous school year who are repeating that grade in the current school year. The dropout rate is the percentage of students who were enrolled in school in the previous school year but were not attending school during the current school year. By asking about the grade that children were attending during the previous school year, it is possible to calculate dropout rates and repetition rates. Repetition and dropout rates approach zero where students nearly always progress to the next grade at the end of the school year. Repetition and dropout rates often vary across grades, indicating points in the school system where students are not regularly promoted to the next grade or they decide to drop out of school. Although an automatic promotion policy does not operate officially in Turkey, very few primary school students repeat grades. Table 2.7.1 indicates that apart from first grade, at which 3 percent are repeating, the rates for grades 2 to 8 are all below 2 percent. 28 | Household Population and Housing Characteristics Table 2.7.1 Grade repetition rates Repetition rates for the de jure household population age 6-24 years by school grade, according to background characteristics, Turkey 2003 School grade Background characteristic 1 2 3 4 5 6 7 8 Sex Male 3.4 2.1 1.4 1.1 1.2 0.7 2.3 2.1 Female 2.7 1.4 0.1 1.6 0.5 1.5 0.5 0.6 Residence Urban 3.0 1.9 0.6 1.6 1.0 0.8 1.5 1.3 Rural 3.1 1.4 1.2 0.8 0.6 1.3 1.4 1.8 Region West 3.4 2.1 0.6 0.8 0.3 0.0 0.9 2.2 South 4.2 1.7 2.0 2.8 3.4 1.7 1.5 0.5 Central 0.0 2.3 0.0 1.8 0.0 2.2 3.3 1.3 North 0.0 3.6 0.0 1.1 1.5 1.5 0.6 2.2 East 4.8 0.5 1.3 1.1 0.8 0.8 0.4 0.8 NUTS 1 Region İstanbul 0.0 4.4 1.2 1.6 0.8 0.0 2.2 1.4 West Marmara 3.0 0.0 0.0 0.0 0.0 0.0 0.0 2.4 Aegean 6.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 East Marmara 5.0 2.0 0.0 0.8 0.0 0.0 1.3 6.9 West Anatolia 0.0 0.0 0.0 2.2 0.0 2.1 2.1 0.0 Mediterranean 4.2 1.7 2.0 2.8 3.4 1.7 1.5 0.5 Central Anatolia 0.0 0.0 0.0 1.9 0.0 1.9 6.7 0.0 West Black Sea 0.0 8.0 0.0 1.3 1.1 3.8 1.3 5.1 East Black Sea 0.0 0.0 0.0 0.0 1.4 0.0 1.3 0.0 Northeast Anatolia 5.5 0.0 3.7 0.0 0.0 0.0 0.0 0.0 Central East Anatolia 3.0 0.0 0.0 0.0 1.4 1.7 0.0 0.0 Southeast Anatolia 5.2 0.8 1.1 2.0 0.7 0.6 0.8 1.8 Total 3.1 1.8 0.8 1.4 0.9 1.0 1.4 1.5 As Table 2.7.2 indicates, dropout rates are also low (2 percent or less) from grades 1 through 7. At the eighth grade, the dropout rate increases to 20 percent. The reason for the high dropout rate at grade 8 is probably because many of the students who complete the 8- year compulsory primary school do not or are unable to move to the next educational level (i.e., high school). There is variation in the rates by residence. For example, rural children are more than two times as likely as urban children to drop out of school at grade 8. Differentials in the dropout rate by region are small. However, at grade 8, significant differentials exist in dropout rates by NUTS 1 regions. Household Population and Housing Characteristics | 29 Table 2.7.2 Dropout rates Dropout rates for the de jure household population age 6-24 years by school grade, according to background characteristics, Turkey 2003 School grade Background characteristic 1 2 3 4 5 6 7 8 Sex Male 0.0 0.3 0.0 0.2 1.7 1.0 0.0 19.1 Female 0.4 0.5 0.8 1.9 2.6 1.3 0.0 21.3 Residence Urban 0.0 0.7 0.2 1.0 1.8 0.9 0.0 14.8 Rural 0.6 0.0 0.8 1.2 2.8 1.7 0.0 32.0 Region West 0.0 1.1 0.0 1.5 1.5 0.0 0.0 17.8 South 0.0 0.0 0.0 0.9 0.5 2.1 0.0 20.7 Central 0.0 0.0 0.0 0.0 2.0 0.0 0.0 19.9 North 1.7 0.0 2.8 2.2 0.0 1.6 0.0 21.5 East 0.3 0.3 0.8 1.0 4.9 3.1 0.0 22.9 NUTS 1 Region İstanbul 0.0 2.2 0.0 0.8 1.2 0.0 0.0 13.6 West Marmara 0.0 0.0 0.0 0.0 0.0 0.0 0.0 25.1 Aegean 0.0 0.0 0.0 0.0 2.4 0.0 0.0 31.6 East Marmara 0.0 0.0 0.0 6.5 2.6 0.0 0.0 13.5 West Anatolia 0.0 0.0 0.0 0.0 0.0 0.0 0.0 17.2 Mediterranean 0.0 0.0 0.0 0.9 0.5 2.1 0.0 20.7 Central Anatolia 0.0 0.0 0.0 0.0 0.0 0.0 0.0 19.8 West Black Sea 0.0 0.0 3.7 0.0 3.5 0.0 0.0 21.9 East Black Sea 2.5 0.0 0.0 4.4 0.0 3.2 0.0 12.1 Northeast Anatolia 0.0 0.0 0.8 0.9 3.3 5.3 0.0 24.8 Central East Anatolia 0.0 0.0 1.3 1.2 2.7 5.1 0.0 18.2 Southeast Anatolia 0.5 0.4 0.5 1.0 7.0 1.3 0.0 25.4 Total 0.2 0.4 0.4 1.0 2.1 1.1 0.0 20.0 2.4 Housing Characteristics The TDHS-2003 gathered information on housing characteristics such as sources of drinking water and time to the nearest water source, type of toilet facilities, main material of the floor, and the number of sleeping rooms in the house. These characteristics are highly correlated with health and are also indicative of socioeconomic status. Table 2.8 presents this information by urban–rural residence. 30 | Household Population and Housing Characteristics Table 2.8 Housing characteristics Percent distribution of households by housing characteristics, according to urban- rural residence, Turkey 2003 Housing characteristic Urban Rural Total Source of drinking water Piped water in house/garden 64.1 16.5 50.1 Public piped water outside house/garden 0.5 0.1 0.4 Public well 0.6 1.8 0.9 Well in house/garden 0.7 6.4 2.4 Piped surface water in house/garden 2.5 60.6 19.6 Spring/public fountain 4.5 10.9 6.4 River/stream/pond/lake/dam 0.0 0.2 0.1 Rainwater 0.0 0.1 0.0 Tanker truck 0.3 0.2 0.3 Bottled water 26.4 2.8 19.5 Water station 0.2 0.1 0.2 Other 0.1 0.2 0.1 Missing 0.1 0.0 0.0 Total 100.0 100.0 100.0 Time to water source Percentage <15 minutes 96.1 93.0 95.2 Sanitation facility Flush toilet 92.7 35.7 75.9 Open pit 1.8 22.9 8.0 Closed pit 5.0 38.5 14.8 No facility, bush/field/public toilet 0.2 1.1 0.5 Other 0.3 1.8 0.7 Missing 0.1 0.0 0.1 Total 100.0 100.0 100.0 Flooring material Earth 0.8 12.0 4.1 Wood planks 10.8 27.1 15.6 Parquet/polished wood 22.1 4.9 17.1 Karo 10.4 4.5 8.6 Cement 22.5 42.0 28.3 Carpet 8.6 4.0 7.2 Marley 21.1 3.3 15.8 Mosaic 2.8 1.0 2.3 Other 0.9 1.0 0.9 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Persons per sleeping room 1-2 77.5 64.9 73.8 3-4 18.5 25.4 20.5 5-6 2.8 6.8 4.0 7+ 0.5 2.1 1.0 Don’t know/missing 0.7 0.8 0.7 Total 100.0 100.0 100.0 Mean number of persons per sleeping room 2.2 2.6 2.3 Number of households 7,643 3,193 10,836 Household Population and Housing Characteristics | 31 Overall, about half of the households get their drinking water from pipes, mainly within their dwelling. The source for drinking water differs considerably by residence. Among urban households, 64 percent get drinking water from pipes in their residence, and less than 1 percent obtains water from a public tap. The second most common source of drinking water in urban areas is bottled water (26 percent), while 5 percent obtain drinking water from a spring/public fountain. 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. More than one in ten rural households obtains water from a spring. Households in rural Turkey are somewhat more likely to be relying on well water than households in urban Turkey (8 percent and 1 percent respectively). Households with no access to drinking water within their own premises were also asked about the time required to fetch water. Overall, 95 percent of households have access to water within 15 minutes. As expected, there is better access to water in urban areas than in rural areas. The lack of availability of sanitary facilities poses a serious health problem. Two- thirds of households have modern sanitation facilities in Turkey. Modern sanitation facilities are much more common in urban areas (93 percent) than in rural areas (36 percent). Twenty-three percent of households have a traditional pit toilet or improved pit toilet (7 percent in urban areas, and 61 percent in rural areas). With regard to flooring, more than a quarter of the TDHS-2003 households live in dwellings with cement floors, and 17 percent in dwellings with a polished wood floor. Another 16 percent have wood planks as flooring material in their dwelling. There are substantial differences in the flooring materials in urban and rural dwellings. Among rural households, 42 percent have a cement floor, compared with about 23 percent of urban households. Wood and marley are also common as a flooring material in urban households: about a half of urban households live in dwellings with wood or marley floors. Twelve percent of households in rural areas have earth floors, compared to less than 1 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 2.8 shows that approximately 74 percent of households have one or two persons per sleeping room, and 21 percent have three to four persons per sleeping room. On average, there are 2.3 persons per sleeping room in Turkey. Rural households have more people per sleeping room than urban households (2.6 and 2.2 persons per sleeping room, respectively). 2.5 Household Durable Goods The availability of durable consumer goods is a good indicator of household socio- economic 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 2.9 presents the availability of selected consumer goods by residence. 32 | Household Population and Housing Characteristics Table 2.9 Household durable goods Percentage of households possessing various durable consumer goods, by urban- rural residence, Turkey 2003 Durable consumer goods Urban Rural Total Refrigerator 96.4 89.5 94.3 Gas or electric oven 78.9 53.0 71.3 Washing machine 86.5 58.8 78.3 Iron 91.3 70.2 85.1 Vacuum cleaner 85.1 52.9 75.6 Television 96.8 89.8 94.7 Telephone 81.5 75.2 79.6 Cellular phone 74.2 50.4 67.2 None of the above 0.4 2.6 1.0 Microwave oven 9.1 2.7 7.2 Dishwasher 28.9 5.7 22.1 Blender/mixer 47.2 19.9 39.2 DVD/VCD player 38.8 14.6 31.7 Video camera 4.4 1.3 3.5 Digiturk/CINE 5/satellite antenna 12.0 19.6 14.3 Air conditioner 6.1 1.4 4.7 Video 8.9 3.4 7.3 Cable TV 8.6 0.4 6.2 Camera 40.3 18.5 33.9 CD player 22.7 7.6 18.2 Computer 15.4 2.6 11.6 Internet 8.4 1.2 6.3 Car 28.1 20.3 25.8 Taxi/minibus/commercial vehicles 4.7 6.6 5.3 Tractor 1.7 19.6 7.0 Motorcycle 3.3 7.6 4.5 Bicycle 20.9 15.3 19.3 Number of households 7,643 3,193 10,836 Most of the population in Turkey enjoys the convenience of electrical appliances. Television sets and refrigerators are present in more than nine in ten households, while almost eight in ten households have a telephone. More than seven 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 as compared to rural areas. Women’s Characteristics and Status | 33 WOMEN’S CHARACTERISTICS AND STATUS 3 Attila Hancıoğlu and Banu Akadlı Ergöçmen The purpose of this chapter is to provide a description of the situation of women in Turkey. This information is useful for understanding the context of reproduction and health and as indicators of the status of women and women’s empowerment. Distributions of interviewed women by various demographic and socioeconomic characteristics are shown in the tables that follow. The main background characteristics that will be used in subsequent chapters, such as age at the time of interview, region, urban-rural residence and education are examined. In addition, information is provided on women’s employment and work status. 3.1 Background Characteristics A description of the basic characteristics of women interviewed in the TDHS-2003 is provided in Table 3.1. The table includes distributions of ever-married women interviewed in the survey, by age, marital status, urban-rural residence, region of residence, and education. Women 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 data on age indicate that a third of women interviewed are less than 30 years of age. The lower proportions in the first two age groups, 15-19 and 20-24 are a result of the ever-married sample; significant proportions of women have not married by these ages. The decline at the upper end of the age categories, on the other hand, is a result of high fertility in the past; the figures imply that successively larger cohorts of women entered the reproductive age groups during the recent decades. Ninety-five percent of women were married at the time of interview, while the rest were either divorced/separated (3 percent) or widowed (2 percent). These figures indicate the rarity of marital dissolution in Turkey. Seventy-one percent of ever-married women live in urban areas. In regard to regional distribution, 4 in every 10 women live in the West, while only 7 percent of ever-married women in the country reside in the North region. With regard to NUTS 1 regions, almost a fifth of ever-married women are in İstanbul, followed by 14 percent in the Aegean and 13 percent in the Mediterranean region. 34 | Women’s Characteristics and Status Table 3.1 Background characteristics of respondents Percent distribution of women by background characteristics, Turkey 2003 Number of women Background characteristic Weighted percent Weighted Unweighted Age 15-19 2.9 238 240 20-24 12.9 1,045 1,080 25-29 18.3 1,480 1,516 30-34 18.4 1,489 1,506 35-39 17.6 1,420 1,410 40-44 16.5 1,330 1,297 45-49 13.3 1,073 1,026 Marital status Married 95.0 7,672 7,686 Divorced/separated 2.9 237 208 Widowed 2.1 166 181 Residence Urban 71.2 5,752 5,976 Rural 28.8 2,323 2,099 Region West 40.7 3,286 2,331 South 12.7 1,028 1,113 Central 23.1 1,867 1,484 North 7.3 590 901 East 16.2 1,305 2,246 NUTS 1 Region İstanbul 18.2 1,470 1,163 West Marmara 4.3 348 384 Aegean 14.3 1,157 549 East Marmara 8.8 710 556 West Anatolia 9.7 784 466 Mediterranean 12.7 1,028 1,113 Central Anatolia 5.8 471 502 West Black Sea 6.3 513 615 East Black Sea 3.6 291 481 Northeast Anatolia 3.0 245 535 Central East Anatolia 4.8 389 566 Southeast Anatolia 8.3 671 1,145 Education No education/Prim. incom. 21.8 1,761 2,032 First level primary 53.7 4,339 4,120 Second level primary 7.4 601 585 High school and higher 17.0 1,374 1,338 Total 100.0 8,075 8,075 The distribution of women by levels of education is striking, and provides clues as to the recent significant changes in reproductive and health behavior in Turkey. While one in every five women has no education or has not completed first level primary school, a significant proportion (17 percent) has completed at least high school. Comparing these figures with the TDHS-1993 results, one finds that women in reproductive age groups today are far more educated than 10 years ago. The proportion of women who have completed at least second level primary school increased from 15 percent in 1993 to 24 percent in 2003, a Women’s Characteristics and Status | 35 relative increase of about 60 percent. On the other hand, the proportion of women who have not completed first level primary school declined from 34 percent to 22 percent in the same period. 3.2 Respondents’ Level of Education by Background Characteristics Table 3.2 shows the distribution of women by the highest level of education attended or completed, according to selected characteristics. The table is shown 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 of particular interest. Table 3.2 Educational attainment by background characteristics Percent distribution of women by highest level of schooling attended or completed, and median number of years of schooling, according to background characteristics, Turkey 2003 Background characteristic No education/ Primary incomplete First level primary Second level primary High school and higher Total Number of women Median years of schooling Age 15-19 26.6 49.8 15.9 7.6 100.0 238 4.5 20-24 14.1 56.7 12.3 16.9 100.0 1,045 4.7 25-29 13.8 53.6 8.0 24.5 100.0 1,480 4.7 30-34 18.4 56.5 7.3 17.8 100.0 1,489 4.6 35-39 23.0 55.5 6.0 15.5 100.0 1,420 4.5 40-44 29.6 50.2 5.4 14.8 100.0 1,330 4.4 45-49 32.8 50.0 4.7 12.5 100.0 1,073 4.4 Residence Urban 18.3 50.9 9.0 21.8 100.0 5,752 4.7 Rural 30.5 60.8 3.6 5.0 100.0 2,323 4.3 Region West 14.6 56.0 8.7 20.7 100.0 3,286 4.7 South 23.6 53.1 7.9 15.4 100.0 1,028 4.5 Central 13.2 62.8 7.2 16.9 100.0 1,867 4.6 North 19.6 57.0 6.5 16.9 100.0 590 4.6 East 51.8 33.9 4.9 9.4 100.0 1,305 0.0 NUTS 1 Region İstanbul 14.2 55.3 9.1 21.4 100.0 1,470 4.7 West Marmara 10.3 64.1 9.1 16.5 100.0 348 4.6 Aegean 16.1 58.3 6.8 18.7 100.0 1,157 4.6 East Marmara 13.6 56.9 9.8 19.7 100.0 710 4.7 West Anatolia 12.0 56.8 8.3 22.9 100.0 784 4.7 Mediterranean 23.6 53.1 7.9 15.4 100.0 1,028 4.5 Central Anatolia 18.0 63.6 6.1 12.3 100.0 471 4.5 West Black Sea 12.4 67.6 5.5 14.6 100.0 513 4.6 East Black Sea 25.5 49.4 7.3 17.9 100.0 291 4.5 Northeast Anatolia 42.1 39.3 5.1 13.4 100.0 245 4.2 Central East Anatolia 50.2 34.1 5.2 10.5 100.0 389 0.0 Southeast Anatolia 56.3 31.9 4.6 7.2 100.0 671 0.0 Total 21.8 53.7 7.4 17.0 100.0 8,075 4.6 36 | Women’s Characteristics and Status Owing to increases and spread of education in recent decades in Turkey, older women are less educated than younger women. A third of women in the final age group have had no educational level completed, but this proportion declines to 14 percent in the 20-24 and 25-29 age groups. A striking 25 percent of women in the latter age group have completed at least high school. Urban women in Turkey are much more likely to have higher education than their rural counterparts. Thirty one percent of rural women have no educational level completed, compared to only 18 percent of urban women. Conversely, while 22 percent of urban women have completed at least high school, this figure is a mere 5 percent in rural areas. The least educated women are in the East region, particularly in Central East Anatolian and Southeast Anatolian NUTS 1 regions, where the median years of schooling is 0.0, compared with the national average of 4.6 years. On the other hand, women in half of the NUTS 1 regions have more than 4.5 median years of schooling. In İstanbul and West Anatolia, more than a fifth of women have completed at least high school. 3.3 Employment and Occupation The TDHS-2003 collected information on the current employment of women. Employment, like education, can be a source of empowerment of women, particularly if it is accompanied with control over income. However, because women may not perceive some of their activities–such as unpaid family work–as employment, it can be difficult to collect information on the subject. In the TDHS-2003, a number of questions were asked about employment to ensure that informal or potentially ill-defined activities were captured. Table 3.3 indicates that 42 percent of women report being employed during the 12- month period before the interview. The majority of these women (27 percent) were working at the time of the survey. The proportion of women not employed during the 12 months preceding the survey is inversely correlated with women’s age–younger women tend to be employed less than their older counterparts. A strong association exists between employment and marital status–employment among women not currently married is substantially higher than among currently married women, possibly as a result of women assuming the role of breadwinner in the absence of a husband. As expected, childbearing has an impact on employment, where nulliparous women are more likely to be employed than women who have children. Also shown in the table is the finding that women in the North are economically more active than their counterparts in other regions. The lowest level of employment is among women in the Central and East regions. The distribution by NUTS 1 regions reveals that more than half of women in the West Marmara, Aegean, West Black Sea, and Northeast Anatolia, and two-thirds of women in the East Black Sea region are employed at any time during the last 12 months. The table also shows that current employment is more common among better educated women (38 percent). Women’s Characteristics and Status | 37 Table 3.3 Employment status Percent distribution of women by employment status, according to background characteristics, Turkey 2003 Employed in the 12 months preceding the survey Background characteristic Currently employed Not currently employed Not employed in 12 months preceding the survey Don't know/ missing Total Number of women Age 15-19 18.7 18.2 63.1 0.0 100.0 238 20-24 18.4 15.7 65.9 0.1 100.0 1,045 25-29 24.1 14.5 61.4 0.0 100.0 1,480 30-34 27.7 16.0 56.3 0.0 100.0 1,489 35-39 35.5 12.4 52.2 0.0 100.0 1,420 40-44 30.4 14.2 55.3 0.0 100.0 1,330 45-49 25.0 14.8 60.2 0.0 100.0 1,073 Marital status Married or living together 26.1 14.6 59.2 0.0 100.0 7,672 Divorced/separated/widowed 43.9 15.2 40.9 0.0 100.0 403 Number of living children 0 30.1 22.9 46.9 0.1 100.0 736 1-2 27.6 12.7 59.7 0.0 100.0 4,234 3-4 24.7 15.6 59.7 0.0 100.0 2,312 5+ 28.0 14.7 57.4 0.0 100.0 794 Residence Urban 21.7 11.1 67.2 0.0 100.0 5,752 Rural 40.1 23.6 36.3 0.0 100.0 2,323 Region West 27.8 14.7 57.5 0.0 100.0 3,286 South 25.3 15.6 59.1 0.0 100.0 1,028 Central 24.9 13.8 61.2 0.0 100.0 1,867 North 32.3 27.2 40.4 0.1 100.0 590 East 26.8 9.4 63.7 0.0 100.0 1,305 NUTS 1 Region İstanbul 24.3 9.3 66.4 0.0 100.0 1,470 West Marmara 29.8 21.7 48.5 0.0 100.0 348 Aegean 37.1 19.8 43.1 0.0 100.0 1,157 East Marmara 25.2 11.5 63.3 0.0 100.0 710 West Anatolia 21.9 11.3 66.8 0.0 100.0 784 Mediterranean 25.3 15.6 59.1 0.0 100.0 1,028 Central Anatolia 20.4 13.5 66.1 0.0 100.0 471 West Black Sea 25.0 27.9 47.0 0.1 100.0 513 East Black Sea 36.2 28.8 34.9 0.0 100.0 291 Northeast Anatolia 42.1 9.5 48.4 0.0 100.0 245 Central East Anatolia 29.4 5.9 64.6 0.2 100.0 389 Southeast Anatolia 19.8 11.4 68.8 0.0 100.0 671 Education No education/Prim. incomp. 26.3 14.5 59.2 0.0 100.0 1,761 First level primary 24.6 16.8 58.7 0.0 100.0 4,339 Second level primary 21.1 9.9 69.0 0.0 100.0 601 High school and higher 38.2 10.4 51.3 0.1 100.0 1,374 Total 27.0 14.7 58.3 0.0 100.0 8,075 38 | Women’s Characteristics and Status 3.4 Decision on Use of Earnings The status of women correlates strongly with their independence in making decisions on the use of their earnings. Table 3.4 shows that around 38 percent of women make their own decisions about the use of their earnings, half of women decide jointly with their husband or others, and 10 percent are not involved in the decisions. Independent decision making with regard to the use of earnings is higher among older women, while 26 percent of women in age group 15-19 have no say in how their earnings are to be used. Independent decision making is also higher among women not currently married, and correlated positively with increasing numbers of children. While urban women are more in control of their earnings, women in the East constitute the group of women in the country with the least say in the use of their earnings. This is particularly highlighted in Southeast Anatolia. A very small proportion of women with high school or more education declared that they do not have a say in the decision on use of earnings (1 percent). Close to two-thirds of these women take such decisions with their husbands or others (63 percent), while independent decision making is the least common among women with less education: women who have no education or have not completed the first level primary school cite others to a larger extent as prime decision-makers in the use of their earnings. Table 3.4 also shows the proportion of household expenditures met by women’s earnings, as perceived by women. In general, women’s earnings meet almost none or less than half of the expenditures of households for 57 percent of cases. Women whose earnings meet half or more of household expenditures account for 42 percent. Women’s earnings are particularly important contributions to household expenditures in cases when the woman is not currently married. Women whose earnings meet all expenditures are mostly women at comparatively older ages, women who are divorced, separated or widowed; nulliparous women; and women with higher education. Although regional variation is not very pronounced, more than 40 percent of women living in the West and North regions meet all or more than half of the expenditures with their earnings. Table 3.5 shows the relationship between the decision on how earnings of women are used and the proportion of household expenditures met by women’s earnings. The table is confined to currently married women since the numbers of women who were not married at the time of interview was too low to allow meaningful analyses. The table shows an interesting relationship between the two variables. In cases when the woman’s earnings do not contribute significantly to meeting the household expenditures, independent decision making among women is more common (56 percent) than the national average (32 percent). Conversely, it is interesting to note that in cases when the woman’s earnings meet all of the household’s needs, significant proportions of women still decide on how their earnings will be used jointly with their husband (55 percent) or have no say in how they will be used–for 9 percent of women, husbands make the decision, for 6 percent, others. Women’s Characteristics and Status | 39 Table 3.4 Decision on use of earnings and contribution of earnings to household expenditures Percent distribution of women employed in the 12 months preceding the survey receiving cash earnings by person who decides how earnings are to be used and by proportion of household expenditures met by earnings, according to background characteristics, Turkey 2003 Person deciding how earnings are used Proportion of expenditures met by earnings Background characteristic Self only Jointly Someone else only Missing Total Almost none/ none Less than half Half or more All Missing Total Number of women Age 15-19 (28.4) (45.4) (26.2) (0.0) 100.0 (25.9) (51.6) (22.5) (0.0) (0.0) 100.0 45 20-24 33.0 54.1 12.8 0.0 100.0 16.4 41.9 34.3 5.4 2.0 100.0 195 25-29 32.7 59.8 7.5 0.0 100.0 13.5 41.0 35.0 9.2 1.2 100.0 376 30-34 35.9 56.6 7.2 0.3 100.0 13.6 48.7 28.0 8.6 1.1 100.0 398 35-39 41.7 46.6 11.4 0.3 100.0 11.0 46.9 29.7 11.0 1.4 100.0 407 40-44 41.3 48.5 10.2 0.0 100.0 9.3 43.6 35.9 9.7 1.6 100.0 365 45-49 41.1 48.9 10.0 0.0 100.0 10.1 41.0 36.1 11.0 1.7 100.0 207 Marital status Married or living together 32.0 57.1 10.7 0.1 100.0 12.7 46.1 33.4 6.4 1.3 100.0 1,782 Divorced/separated/ widowed 84.6 12.3 3.1 0.0 100.0 10.0 31.2 24.3 32.4 2.0 100.0 210 Number of living children 0 37.0 55.9 7.1 0.0 100.0 12.8 30.7 41.7 13.7 1.1 100.0 267 1-2 36.5 55.9 7.6 0.1 100.0 11.3 44.7 33.8 9.1 1.1 100.0 1,177 3-4 39.8 44.2 15.7 0.2 100.0 13.7 50.8 26.9 6.9 1.7 100.0 445 5+ 42.2 38.8 19.1 0.0 100.0 18.7 51.5 17.0 8.1 4.7 100.0 103 Residence Urban 40.3 53.8 5.9 0.1 100.0 10.7 42.8 36.2 9.2 1.1 100.0 1,551 Rural 27.9 47.5 24.3 0.2 100.0 18.6 50.7 19.3 9.0 2.4 100.0 442 Region West 36.8 54.7 8.5 0.0 100.0 10.9 43.5 34.9 9.6 1.0 100.0 1,048 South 37.0 50.4 11.8 0.8 100.0 15.0 46.8 28.5 8.1 1.7 100.0 254 Central 38.7 51.8 9.5 0.0 100.0 12.7 47.3 31.0 8.5 0.5 100.0 405 North 47.8 46.1 6.1 0.0 100.0 14.4 44.2 31.8 9.5 0.0 100.0 121 East 32.9 46.9 20.3 0.0 100.0 15.9 41.6 27.0 8.9 6.6 100.0 165 NUTS 1 Region İstanbul 44.3 49.4 6.4 0.0 100.0 10.0 40.8 39.9 8.3 1.0 100.0 455 West Marmara 22.2 67.3 10.6 0.0 100.0 18.2 34.6 37.7 8.4 1.1 100.0 102 Aegean 30.3 54.5 15.2 0.0 100.0 10.4 51.2 27.9 9.3 1.2 100.0 428 East Marmara 40.3 56.2 3.5 0.0 100.0 9.9 48.3 30.0 11.9 0.0 100.0 173 West Anatolia 37.1 59.7 3.2 0.0 100.0 8.0 43.7 37.8 9.9 0.6 100.0 176 Mediterranean 37.0 50.4 11.8 0.8 100.0 15.0 46.8 28.5 8.1 1.7 100.0 254 Central Anatolia 45.6 46.6 7.8 0.0 100.0 21.6 41.6 27.3 8.5 1.0 100.0 82 West Black Sea 46.4 44.4 9.2 0.0 100.0 20.4 40.0 29.0 10.6 0.0 100.0 96 East Black Sea 48.6 46.8 4.6 0.0 100.0 10.4 44.5 35.8 9.3 0.0 100.0 60 Northeast Anatolia 38.4 54.5 7.1 0.0 100.0 27.0 41.3 26.0 3.1 2.5 100.0 32 Central East Anatolia 45.7 42.5 11.8 0.0 100.0 19.1 45.9 25.8 6.0 3.3 100.0 44 Southeast Anatolia 24.5 46.3 29.2 0.0 100.0 10.5 39.5 27.9 12.4 9.8 100.0 89 Education No educ./Prim.incom. 34.7 43.2 21.7 0.3 100.0 12.2 47.5 27.9 8.2 4.2 100.0 314 First level primary 39.1 48.8 12.0 0.0 100.0 16.0 52.7 23.3 6.9 1.1 100.0 932 Second level primary 40.4 52.8 6.8 0.0 100.0 16.7 42.7 30.4 10.2 0.0 100.0 149 High school and higher 36.0 62.6 1.3 0.2 100.0 6.0 30.8 49.6 12.9 0.8 100.0 598 Total 37.6 52.4 9.9 0.1 100.0 12.4 44.6 32.4 9.2 1.4 100.0 1,992 Note: Parentheses indicate that a figure is based on 25-49 unweighted cases. 40 | Women’s Characteristics and Status Table 3.5 Women's control over earnings Percent distribution of currently married women who received cash earnings for work in the past 12 months by person who decides how earnings are used, according to the proportion of household expenditures met by earnings, Turkey 2003 Contribution to household expenditures Self only Jointly with husband Jointly with someone else Husband only Someone else only Missing Total Number of women Almost none/none 55.7 31.6 0.0 11.1 1.2 0.5 100.0 227 Less than half 33.5 54.1 0.4 10.1 1.9 0.0 100.0 822 Half or more 22.1 71.9 0.2 5.3 0.5 0.0 100.0 595 All 30.3 55.2 0.0 9.0 5.5 0.0 100.0 114 Missing (11.5) (26.8) (0.0) (42.9) (14.2) (4.6) 100.0 24 Total 32.0 56.9 0.2 9.0 1.8 0.1 100.0 1,782 Note: Parentheses indicate that a figure is based on 25-49 unweighted cases. 3.5 Domestic Violence: Women’s Attitudes towards Being Subject to Physical Violence Recent years have witnessed an increasing interest in violence against women, in particular domestic violence. Domestic violence against women is acknowledged worldwide as a violation of the basic human rights of women. Tolerance and experience of domestic violence form significant barriers to the empowerment of women and women’s autonomy in all spheres of social life and have adverse consequences for women’s health, health-seeking behavior, and the health of their children. In the TDHS-2003, women were asked a number of questions on their attitudes regarding especially physical violence, which is one of the special types of domestic violence, with regard to whether they viewed physical violence as justified under given circumstances. Women were asked whether a husband would be justified in beating his wife for each of the following reasons separately: if she burns the food, if she argues with him, if she spends too much money, if she neglects the children, and if she refuses to have sex with him. Table 3.6 gives the percentages of ever-married women who agree with the specified reasons for wife beating by background characteristics. Thirty-nine percent of women accept at least one reason as a justification for wife beating. Women are most likely to think that wife beating would be justified in cases when the woman argues with the husband (29 percent), spends too much money (27 percent) and neglects the children (23 percent). Only 6 percent of women agree that wife beating would be justified if the woman burns the food. Younger women, currently married women, and women with high fertility are more likely than their counterparts to think that wife beating is justified for at least one of the reasons. Women’s Characteristics and Status | 41 Table 3.6 Women's attitude toward wife beating Percentage of women who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Turkey 2003 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Spends too much money Neglects the children Refuses to have sex with him Agrees with at least one specified reason Number of women Age 15-19 8.3 52.4 38.7 33.1 21.5 63.0 238 20-24 4.9 31.2 28.5 23.4 12.6 40.2 1,045 25-29 3.4 25.0 21.9 19.9 12.2 35.3 1,480 30-34 4.8 26.9 24.1 22.7 12.8 37.0 1,489 35-39 7.3 30.0 29.3 23.6 19.1 40.3 1,420 40-44 7.2 28.1 29.1 23.8 19.6 39.2 1,330 45-49 7.0 30.2 28.5 24.8 21.5 39.8 1,073 Marital status Married or living together 5.7 29.5 27.3 23.2 16.3 39.6 7,672 Divorced/separated/widowed 7.1 21.7 21.8 23.4 15.2 31.5 403 Number of living children 0 5.9 30.0 26.9 24.0 14.5 37.9 736 1-2 3.7 22.9 20.7 18.2 11.1 31.8 4,234 3-4 6.5 33.3 31.0 26.8 19.9 44.7 2,312 5+ 14.8 48.6 49.4 38.8 35.2 63.6 794 Residence Urban 3.3 22.2 20.3 18.9 12.0 32.1 5,752 Rural 12.0 46.0 43.7 33.7 26.8 56.6 2,323 Region West 3.5 22.9 21.0 19.2 12.6 32.5 3,286 South 4.6 31.1 30.7 24.8 17.4 43.2 1,028 Central 7.0 34.0 30.0 24.6 16.5 42.9 1,867 North 4.6 24.5 25.0 23.5 15.0 35.5 590 East 11.3 37.9 36.0 29.7 25.1 49.2 1,305 NUTS 1 Region İstanbul 1.6 17.7 16.7 15.2 9.5 26.8 1,470 West Marmara 4.8 24.2 23.9 21.1 12.2 35.0 348 Aegean 8.5 37.2 32.6 28.6 20.2 46.7 1,157 East Marmara 2.8 21.9 19.4 18.4 13.1 31.3 710 West Anatolia 6.7 27.7 25.4 21.1 12.1 35.1 784 Mediterranean 4.6 31.1 30.7 24.8 17.4 43.2 1,028 Central Anatolia 4.8 36.1 30.7 25.9 17.8 47.8 471 West Black Sea 5.3 28.7 28.5 24.2 15.3 39.6 513 East Black Sea 3.8 23.6 22.7 20.9 14.5 33.7 291 Northeast Anatolia 12.8 38.5 37.7 30.9 25.2 50.4 245 Central East Anatolia 10.0 34.2 33.2 28.6 21.9 45.9 389 Southeast Anatolia 11.6 39.8 37.1 30.0 26.9 50.6 671 Education No education/Prim. incomp. 14.9 49.2 47.5 38.5 33.2 62.1 1,761 First level primary 4.6 30.6 28.0 24.4 15.7 42.1 4,339 Second level primary 0.7 13.2 10.4 11.2 4.4 20.8 601 High school and higher 0.2 5.3 5.2 5.0 1.7 8.8 1,374 Employment Not employed 5.1 28.1 25.6 22.4 15.4 38.2 5,892 Employed for cash 3.0 21.5 22.1 18.4 11.2 30.3 1,339 Employed not for cash 15.3 47.8 45.2 36.7 30.6 60.7 842 Total 5.8 29.1 27.0 23.2 16.3 39.2 8,075 42 | Women’s Characteristics and Status There are differences in terms of justification of violence between women who live in urban versus rural areas, and between women living in different regions. While 57 percent of women in rural areas think that wife beating would be justified in at least one of the circumstances specified, the proportion drops to 32 percent for urban women. For both urban and rural women, arguing with the husband is the most often agreed reason for wife beating. Almost half of women in the East agree with at least one of the circumstances specified (49 percent). In two NUTS 1 regions in the western areas of the country, Northeast Anatolia and Southeast Anatolia, the proportion is above 50 percent. The proportion drops to 33 percent in the West and 36 percent in the North. The proportion is at its lowest in İstanbul. The table clearly shows the importance of women’s education in the elimination of wife beating, although it is still interesting that even among women who have completed at least high school (have completed at least 11 grades), 9 percent agree to wife beating for some reason. Among women with little or no education, two-thirds of women (62 percent) agree with at least one specified reason for wife beating. The most common reason cited by these women is arguing with the husband (49 percent) and spending too much money (48 percent). As expected, women who are not employed in the formal sector but who are possibly employed in the family business justify wife beating more than their counterparts (61 percent). 3.6 Child Care While Working Table 3.7 focuses on the welfare of children under six years of age whose mothers are employed. Of women who worked in the 12 months prior to the survey, 63 percent had no children under 6 years of age. For the 37 percent of women who have one or more children, childcare is an important issue in participating in the labor force. Overall, in Turkey the main source of child care is either the mother or the relatives. The proportion of institutional care is very small with less than 5 percent. Relatives constitute a substantial proportion in taking care of children. In 37 percent of the cases, the mother takes care of children indicating that she is either taking the child with her to work or she is working at home. In one fifth of the cases it is the husband’s mother (21 percent) who takes care of the children under 6 years of age while their mother is at work. It is seen that besides the mother and mother-in-law, an older female child sometimes takes the responsibility (10 percent) for her brother(s)/sister(s). If it is the mother who takes care of the children less than six years of age, then these women are more likely to be rural women, women who do not have education above second level primary school, women living in the South and East regions and those who work on an occasional basis. It is worth noting that having an agricultural or non agricultural occupation does not cause much difference in terms of child care for children less than six while mother is at work (36 and 38 percent respectively). On one hand, the results reflect the presence of intra-family solidarity in childrearing; on the other, they also underline the patriarchal structure of the society. When persons other than the mother are considered, it is the husband’s mother rather than the woman’s mother who is taking care of children. Women’s Characteristics and Status | 43 3.7 Child care while working Percentage of employed women with and without a child under six years of age and percent distribution of employed mothers of a child under six years of age by person who cares for child while mother is at work, according to background characteristics, Turkey 2003 Child's caretaker while mother is at work Background characteristic No chil- dren under 6 years One or more chil- dren Respon- dent Hus- band/ part- ner Older female child Wo- man's mother Hus- band's mother Older male child Other rel- ative Ser- vant, hired help Institu- tional care No work since birth Other Miss- ing Total Number of women Residence Urban 67.4 32.6 34.0 2.7 7.4 13.4 16.5 0.5 5.4 7.6 8.9 2.9 0.4 0.3 100.0 1,887 Rural 58.2 41.8 40.2 2.3 13.5 4.8 26.2 1.6 7.5 0.5 0.3 2.2 0.8 0.2 100.0 1,479 Education No educ./Prim. 60.2 39.8 39.8 0.7 28.3 3.2 15.7 3.4 6.6 0.0 0.0 0.7 1.3 0.4 100.0 718 First level prm. 64.6 35.4 44.4 3.1 7.3 8.9 24.4 0.3 7.2 0.7 0.3 2.7 0.6 0.1 100.0 1,793 Second level prm. 63.1 36.9 43.7 7.7 1.5 9.1 21.2 1.6 7.2 0.0 4.0 3.3 0.0 0.6 100.0 187 High school and higher 63.4 36.6 13.3 1.6 0.2 16.2 20.2 0.0 4.4 18.5 21.3 4.0 0.0 0.4 100.0 668 Region West 72.3 27.7 30.1 2.3 6.4 15.6 20.8 1.0 5.6 6.2 7.4 4.2 0.2 0.2 100.0 1,398 South 59.4 40.6 47.2 2.8 7.5 9.4 17.6 1.3 5.3 3.4 2.4 1.9 0.3 0.9 100.0 421 Central 63.0 37.0 35.7 3.3 7.2 9.3 24.1 0.8 7.3 4.1 5.6 1.8 0.7 0.0 100.0 724 North 63.9 36.1 34.9 4.8 11.8 2.3 31.1 0.9 7.4 1.8 3.4 1.2 0.0 0.3 100.0 351 East 40.5 59.5 43.1 0.6 20.2 2.7 17.4 1.3 7.2 2.3 1.6 2.0 1.5 0.1 100.0 473 NUTS 1 Region İstanbul 73.1 26.9 34.7 2.5 8.5 11.9 11.7 2.1 4.8 6.6 12.1 5.0 0.0 0.0 100.0 494 West Marmara 71.7 28.3 26.1 1.6 10.0 14.1 28.6 2.3 3.2 7.9 0.0 3.2 1.6 1.6 100.0 179 Aegean 72.1 27.9 30.8 3.2 3.2 15.6 30.0 0.0 3.6 4.4 5.9 3.3 0.0 0.0 100.0 659 East Marmara 71.7 28.3 18.0 2.3 4.7 16.1 27.5 1.4 14.5 8.6 4.2 2.6 0.0 0.0 100.0 261 West Anatolia 58.3 41.7 35.0 0.0 8.2 14.7 13.0 1.0 9.4 4.8 10.3 2.6 1.0 0.0 100.0 260 Mediterranean 59.4 40.6 47.2 2.8 7.5 9.4 17.6 1.3 5.3 3.4 2.4 1.9 0.3 0.9 100.0 421 Central Anatolia 57.7 42.3 33.9 5.4 14.2 7.2 25.5 0.0 3.5 2.4 3.7 3.0 1.2 0.0 100.0 159 West Black Sea 69.3 30.7 40.9 4.2 4.3 1.7 33.2 0.0 8.3 2.3 3.3 1.9 0.0 0.0 100.0 271 East Black Sea 56.7 43.3 39.9 6.2 13.9 3.0 24.5 1.4 7.2 1.5 2.0 0.0 0.0 0.5 100.0 189 Northeast Anatolia 46.7 53.3 60.7 0.0 11.2 1.9 16.2 1.2 4.5 1.0 1.4 1.4 0.0 0.5 100.0 126 Central East Anatolia 41.9 58.1 35.5 0.0 26.6 2.6 17.4 0.7 7.2 1.5 3.0 2.2 3.2 0.0 100.0 137 Southeast Anatolia 35.7 64.3 38.7 1.3 20.9 3.1 17.9 1.7 8.5 3.5 0.9 2.2 1.3 0.0 100.0 209 Occupation Agricultural 61.1 38.9 35.7 1.6 14.9 6.5 28.8 1.3 7.8 0.2 0.0 2.1 0.5 0.4 100.0 1,323 Non-agricultural 64.8 35.2 38.2 3.1 7.2 10.9 16.0 0.9 5.5 6.7 7.9 2.9 0.7 0.2 100.0 2,042 Continuity of employment All year 65.9 34.1 28.8 1.8 11.7 10.1 20.0 0.5 5.7 8.3 9.2 2.9 0.7 0.2 100.0 1,705 Seasonal 61.8 38.2 39.0 2.1 11.4 5.7 27.4 1.2 8.3 0.1 0.7 2.8 0.8 0.4 100.0 1,203 Occasional 58.0 42.0 58.3 5.4 4.3 12.9 11.0 2.3 4.7 0.3 0.0 0.8 0.0 0.0 100.0 454 Missing * * * * * * * * * * * * * * 100.0 4 Total 63.3 36.7 37.1 2.5 10.4 9.0 21.3 1.1 6.5 4.0 4.6 2.6 0.6 0.3 100.0 3,366 Note: An asterisk indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Fertility | 45 FERTILITY 4 İsmet Koç and Erhan Özdemir This chapter looks at a number of fertility indicators including levels, patterns, and trends in both current and cumulative fertility; the length of birth intervals; and the age at which women initiate childbearing. Information on current and cumulative fertility is essential in monitoring the progress and evaluating the impact of the population program in Turkey. The data on birth intervals are important since short intervals are strongly associated with childhood mortality. The age at which childbearing begins may also have a major impact on the health and well-being of both the child and the mother. Data on childbearing patterns were collected in the TDHS-2003 in several ways. First, each woman was asked a series of questions on the number of her sons and daughters living with her, the number living elsewhere, and the number who may have died. Next, a complete history of all of the woman’s births was obtained, including the name, sex, month and year of birth, age, and survival status for each of the births. For living children, a question was asked about whether the child was living in the household or away. For dead children, the age at death was recorded. 4.1 Current Fertility The level of current fertility is one of the most important topics in this report because of its direct relevance to population policies and programs. Measures of current fertility presented in this chapter include age-specific fertility rates, the total fertility rate, the general fertility rate, and the crude birth rate. These rates are generally presented for the three-year period preceding the survey. The three-year period was chosen for calculating these rates (rather than a longer or a shorter period) to provide the most current information, to reduce sampling error, and to avoid problems of the displacement of births. Age-specific fertility rates are useful in understanding the age pattern of fertility. Numerators of age-specific fertility rates are calculated by identifying live births that occurred in the 1 to 36 months preceding the survey (determined from the date of interview and date of birth of the child), and classifying them by the age (in five-year age groups) of the mother at the time of the child’s birth. The denominators of these rates are the number of woman-years lived in each of the specified five-year age groups during the 1 to 36 months preceding the survey. Although information on fertility was obtained only for ever-married women, the age- specific rates are presented for all women regardless of marital status. Data from the household questionnaire on the age structure of the population of never-married women were used to calculate the all-women rates. This procedure assumes that women who have never been married have had no children. 46 | Fertility The total fertility rate (TFR) is a useful measure for examining the overall level of current fertility. TFR is a construct of the age-specific rates computed by summing the age- specific rates and multiplying by five. It can be interpreted as the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the currently observed age-specific rates. The general fertility rate (GFR) represents the annual number of births in a population per 1,000 women age 15-44. The crude birth rate (CBR) is the annual number of births in a population per 1,000 persons. Both measures are based on the birth history data for the three-year period before the survey and the age-sex distribution of the household population. Current estimates of fertility levels by residence are presented in Table 4.1. The total fertility rate indicates that if fertility rates were to remain constant at the level prevailing during the three-year period before the TDHS-2003 (approximately June 2001 to May 2004), a woman in Turkey would bear 2.23 children during her lifetime. In rural areas, the TFR is 2.65 births per woman, and decreases around two children (2.06) in urban areas. When compared with evidence from previous demographic surveys, the urban-rural gap in fertility levels appears to be closing in Turkey. Table 4.1 and Figure 4.1 show that women in Turkey experience their prime reproductive years during their twenties. According to current age schedule of fertility, the average woman in Turkey will have one child by age 25 and two children by age 30. At every age rural women bear more children than urban women. The rural age-specific fertility rates rise sharply from age 15-19 to the peak at age 20-24, and then gradually decline. On the other hand, the urban age-specific fertility rates assume a more gradual pattern, an indication both Table 4.1 Current fertility Age-specific and cumulative fertility rates, general fertility rate, and crude birth rate for the three years preceding the survey, by urban- rural residence, Turkey 2003 Age group Urban Rural Total 15-19 44 47 46 20-24 126 161 136 25-29 126 158 134 30-34 71 94 78 35-39 33 48 38 40-44 11 16 12 45-49 0 6 2 TFR 15-49 2.06 2.65 2.23 TFR 15-44 2.06 2.62 2.22 GFR 15-44 74 90 79 CBR 19 21.1 19.7 Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. TFR: Total fertility rate expressed per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Fertility | 47 of delayed marriage and some deliberate attempt to postpone or terminate births by urban women. Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence 0 30 60 90 120 150 180 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Births per 1,000 women Urban Rural Total Table 4.1 also presents two other summary measures of fertility: the crude birth rate and the general fertility rate. The crude birth rate in Turkey is 19.7 births per 1,000 population. As with TFR, there is a slight differential in this rate by residence: 19 births per 1000 in urban areas versus 21.1 births per 1,000 in rural areas. The general fertility rate of 79 indicates that 1,000 women age 15-44 would have 79 live births per year. The GFR also indicates a significant urban-rural difference. 4.2 Fertility Differentials Table 4.2 highlights TFRs for the three years preceding the survey by background characteristics. The greatest regional variation in fertility is seen between East region and the rest of Turkey. With a TFR of 3.65, women in eastern part of Turkey have a TFR that is about one and a half births more than women elsewhere in Turkey who exhibit TFRs below 2.1, known as replacement level, with the exception of South region, which exhibits slightly over replacement fertility. Among the NUTS 1 regions, the fertility is below the replacement level (1.83) in İstanbul, while in the Southeast Anatolia it is twice the level of replacement fertility. Table 4.2 also shows the mean number of children ever born (CEB) to women age 40- 49. Trends in fertility can be inferred by comparing the TFR (a measure of current fertility) with the number of CEB (a measure of completed fertility). If fertility is stable over time in a population, the TFR and the mean CEB for women 40-49 will be similar. If fertility levels have been falling, the TFR will be substantially lower than the mean CEB among women age 40-49. The comparison of the TFR with the mean CEB among women 40-49 in Table 4.2 TDHS-2003 48 | Fertility suggests that fertility has fallen sharply in Turkey over the past several decades. Women age 40-49 had an average of 3.5 births during their lifetime, over one birth more than women bearing children will have at the current rates. The decline in fertility implied by a comparison of the TFR with completed fertility has been greater in rural than in urban areas. The largest implied decline in fertility by region is observed in East region, where the TFR was approximately 2 and a half births lower than the mean number of children ever born to women 40-49. Table 4.2 presents marked differences in fertility levels and trends by education. The TFR decreases rapidly with increasing educational level, from 3.7 births among women with no education to 1.4 births among women who had completed high school or higher. The differentials in completed fertility across educational groups are even more striking. The mean number of children ever born is 5 among women age 40-49 with no education, compared with 2 among women who have completed high school or higher. With regard to the trend in fertility, the decline in fertility implied by a comparison of the TFR with the mean CEB is substantial for women with no education. Another indicator of current fertility, the percentage of women who are currently pregnant, is included in Table 4.2. Overall, slightly more than 4 percent of the TDHS-2003 respondents were pregnant at the time of the survey. Women living in the eastern part of Turkey have the highest percentage currently pregnant (7 percent), while the percentage is Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women 15-49 currently pregnant, and mean number of children ever born to women age 40-49, by background characteristics, Turkey 2003 Background characteristic Total fertility rate1 Percentage currently pregnant Mean number of children ever born to women age 40-49 Region West 1.88 3.1 2.90 South 2.30 4.1 3.72 Central 1.86 3.9 3.43 North 1.94 2.9 3.41 East 3.65 6.9 6.07 Selected NUTS 1 Regions İstanbul 1.83 2.9 3.09 Southeast Anatolia 4.19 6.7 6.61 Education No educ./Prim. incomp. 3.65 5.6 4.98 First level primary 2.39 4.1 3.21 Second level primary 1.77 2.3 2.54 High school and higher 1.39 3.8 1.96 Total 2.23 4.1 3.54 1 Women age 15-49 years Fertility | 49 lowest in the West and North regions (3 percent). Surprisingly, the percentage of women who were pregnant is higher for women with a high school or higher education than for women with a secondary education. This may be due at least in part to the fact that, on average, highly-educated women are younger than women in the other education categories and thus more likely to be in the family-building stage than other women. 4.3 Fertility Trends Trends in fertility can be assessed in several other ways. TFR estimates from the TDHS-2003 can be compared with estimates obtained in earlier surveys. Fertility changes can also be examined by using data from the birth histories obtained from the TDHS-2003 respondents to look at the trend in age-specific fertility rates for successive five-year periods before the survey. 4.3.1 Comparison with Previous Surveys Table 4.3 shows the TFR estimates from a series of surveys conducted in Turkey during the period 1978 through 2003. The surveys vary in the timeframes for which the TFR estimates are available. For example, the rates from the 1978, 1988 and 1993 surveys are based on births in a one-year period before the survey, while the rates for the TDHS-1998 and TDHS-2003 surveys are based on a three-year period before the interview date. Table 4.3 Trends in fertility Age specific fertility rates (per 1,000 women) and total fertility rate, the 1978 Turkey Fertility Survey, the 1988 Turkey Population and Health Survey, and the 1993, 1998 and 2003 Turkey Demographic and Health Surveys Age TFS- 1978 TPHS- 1988 TDHS- 1993 TDHS- 1998 TDHS- 2003 15-19 93 45 56 60 46 20-24 259 193 179 163 136 25-29 218 183 151 150 134 30-34 154 102 94 93 78 35-39 101 55 38 42 38 40-44 38 19 12 13 12 45-49 2 7 0 1 2 TFR 15 49 4.33 3.02 2.65 2.61 2.23 Note: 1978, 1988 and 1993 rates refer to the year before the survey; 1998 and 2003 rates refer to the 3-year period before the survey. As Table 4.3 and Figure 4.2 show, fertility levels have declined almost continuously in Turkey over the past 25 years, from a level of 4.3 births per woman at the time of the TFS- 1978 to 2.2 births per woman at the time of the TDHS-2003. The decline in fertility was especially rapid during the period between the 1970s and the 1980s. After the TFR reached a level of below 3 births per woman at the time of the TDHS-1993, the pace of fertility decline slowed somewhat, and stabilized around 2.6 births on average in the 1990s. However after a stabilization period in fertility during the 1990s, TDHS-2003 puts forward a fertility decline by 50 | Fertility 15 percent in the period of 1998 and 2003. The fertility level reached by Turkey in 2000s is slightly over the replacement level of fertility. Figure 4.2 Trends in Fertility 0 50 100 150 200 250 300 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Mother's age Births per 1,000 women TFS-1978 TPHS-1988 TDHS-1993 TDHS-1998 TDHS-2003 4.3.2 Retrospective Data from TDHS-2003 Birth Histories Fertility trends can also be investigated using retrospective data from the birth histories collected from respondents in a single survey. The age-specific fertility rates shown in Table 4.4 and Figure 4.3 were generated from the birth history data collected in the TDHS- 2003. The numerators of the rates are classified by five-year segments of time preceding the survey and the mother’s age at the time of birth. Because women age 50 years and over were not interviewed in the TDHS-2003, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 45-49 for the period 5-9 years and more prior to the survey, because women in that age group would have been 50 years or older at the time of the survey. Table 4.4 Age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age, Turkey 2003 Number of years preceding the survey Mother's age 0-4 5-9 10-14 15-19 15-19 51 61 86 83 20-24 142 180 200 222 25-29 141 156 159 187 30-34 84 103 96 [113] 35-39 38 37 [45] 40-44 12 [12] 45-49 [2] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Fertility | 51 Figure 4.3 Age-specific Fertility Rates during the Last 20 Years 0 50 100 150 200 250 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Mother's age Births per 1,000 women 0-4 5-9 10-14 15-19 The results in Table 4.4 and Figure 4.3 confirm that fertility has fallen substantially among all age groups, with the most rapid relative decline occurring in the 15-19 age group. Overall, the cumulative fertility rate for women age 15-34 decreased by one birth, from 3.0 births per woman during the period 15-19 years before the survey to 2.1 births per woman in the five-year period preceding the survey. Table 4.5 presents fertility rates for ever-married women by duration since first marriage for five-year periods preceding the survey. The decline in fertility has occurred at all marital durations; however, the decline is greatest among women with longer marital durations. Fertility within the first several years of marriage typically remains resistant to change, even when fertility is declining, because fertility decline usually begins among older Table 4.5 Fertility by marital duration Fertility rates for ever-married women by duration since first marriage in years, for five-year periods preceding the survey, Turkey 2003 Number of years preceding the survey Marriage duration at birth 0-4 5-9 10-14 15-19 0-4 278 293 324 334 5-9 154 177 170 213 10-14 89 99 110 153 15-19 41 56 78 [111] 20-24 17 27 [49] [117] 25-29 9 [16] [38] Note: Age-specific fertility rates are per 1,000 women. Estimates enclosed in brackets are truncated. TDHS-2003 52 | Fertility women who want to stop childbearing, not among young couples postponing births. Table 4.5 indicates rapid declines in fertility for all marital durations of five or more years, and a 17 percent decline for marriages of less than five years. 4.4 Children Ever Born and Living Table 4.6 presents the distribution of all women and of currently married women by the total number of children ever born. The distribution is the outcome of each woman’s lifetime fertility. It reflects the accumulation of births over the past 30 years and therefore its relevance to the current situation is limited. However, the information is useful in looking at how average family size varies across age groups and for looking at the level of primary infertility. Since only ever-married women were interviewed in the TDHS-2003, information on the reproductive histories of never-married women is not available. However, virtually all births in Turkey occur within marriage; thus, in calculating these fertility measures for all women, never-married women were assumed to have had no births. The marked differences between the results for currently married women and for all women at the younger ages are due to the comparatively large numbers of never-married women in those age groups who, as noted, are assumed to have had no births. Table 4.6 Children ever born and living Percent distribution of all women and of currently married women by number of children ever born (CEB) and mean number of children ever born and living, according to five-year age groups, Turkey 2003 Number of children ever born Mean number of Age of mother 0 1 2 3 4 5 6 7 8 9 10+ Total percent Number of women Mean number of CEB living children ALL WOMEN 15-19 94.3 4.8 0.6 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,003 0.07 0.07 20-24 61.8 22.5 11.5 3.1 0.8 0.3 0.0 0.0 0.0 0.0 0.0 100.0 2,101 0.59 0.57 25-29 27.9 24.0 28.8 11.2 4.5 2.1 0.5 0.4 0.5 0.0 0.0 100.0 1,849 1.54 1.48 30-34 13.4 14.8 32.4 20.4 9.2 3.7 2.4 2.0 0.8 0.7 0.2 100.0 1,622 2.39 2.25 35-39 8.3 9.6 30.4 23.5 12.9 6.0 3.5 2.2 1.3 1.0 1.3 100.0 1,481 2.93 2.69 40-44 5.3 5.6 28.5 23.3 13.6 8.7 6.1 2.8 2.2 1.3 2.5 100.0 1,371 3.44 3.11 45-49 4.3 5.8 25.2 21.7 16.5 10.1 5.5 3.7 2.1 1.6 3.7 100.0 1,089 3.67 3.23 Total 36.1 13.4 21.1 13.1 7.0 3.7 2.1 1.3 0.8 0.5 0.8 100.0 11,517 1.84 1.69 CURRENTLY MARRIED WOMEN 15-19 51.5 40.8 5.5 1.7 0.5 0.0 0.0 0.0 0.0 0.0 0.0 100.0 237 0.59 0.56 20-24 23.4 44.9 23.2 6.2 1.7 0.6 0.0 0.0 0.0 0.0 0.0 100.0 1,019 1.20 1.15 25-29 9.4 29.6 36.5 14.2 5.7 2.7 0.7 0.5 0.2 0.0 0.0 100.0 1,435 1.95 1.87 30-34 4.9 15.1 36.1 22.8 10.4 4.0 2.6 2.6 1.1 0.8 0.2 100.0 1,423 2.65 2.49 35-39 3.8 8.4 32.2 25.0 13.9 6.5 3.8 2.4 0.4 1.1 1.4 100.0 1,333 3.13 3.88 40-44 2.3 4.7 29.2 24.8 14.4 9.4 5.8 3.1 5.0 1.4 2.6 100.0 1,223 3.59 3.25 45-49 2.6 5.6 25.8 22.4 16.5 10.4 5.7 3.7 4.9 1.7 3.5 100.0 1,001 3.75 3.30 Total 8.7 18.5 30.4 19.0 10.1 5.3 3.0 1.9 1.9 0.8 1.2 100.0 7,671 2.64 2.43 Fertility | 53 Table 4.6 shows that on the average a woman in Turkey has given birth to 1.84 children. Out of that number, 1.69 children are still alive, indicating that 6 percent of the children ever born to TDHS-2003 respondents have died. The number of children that women have borne increases directly with age, reflecting the natural family-building process. Women age 45-49, who are approaching the end of their childbearing period, have had an average of 3.8 births. Reflecting the high levels of fertility prevailing during the 30-year period when those women were bearing children, approximately 4 percent of women in the cohort have had 10 or more births. As expected, the proportion surviving declines with increasing age of mother. Among women age 45-49, the mean number of children ever born is almost a half child greater than the mean number of surviving children. The percentage of women in their forties who have never had children provides an indicator of the level of primary infertility –the proportion of women who are unable to bear children at all. Since voluntary childlessness is rare in Turkey, it is likely that married women with no birth are unable to bear children. The TDHS-2003 results suggest that primary fertility is low; less than 3 percent of married women age 45-49 report that they have had no children. 4.5 Birth Intervals A birth interval is the period between two successive live births. Research has shown that children born soon after a previous birth (i.e., within 24 months) are at greater risk of illness and death than those born after a longer interval. In addition, short birth intervals may have consequences for other children in the family. The occurrence of closely spaced births gives the mother insufficient time to restore her health, which may limit her ability to take care of her children. The duration of breastfeeding for the older child may also be shortened if the mother becomes pregnant. Table 4.7 shows the percent distribution of non-first births in the five years preceding the survey by length of the previous birth interval. Birth intervals are relatively long, with about three-quarters of all non-first births occurring at least two years after the previous birth. Approximately a half of births took place at least three years after a prior birth. The median interval is approximately 36 months, which is about a year longer than the minimum interval considered safe. Although the majority of non-first births are appropriately spaced, 27 percent were born too soon after a prior birth, i.e., within 24 months of a previous birth. Younger women have shorter birth intervals than older women. The median interval varies from 23 months among the small number of births to women age 15-19 to 45 months among births to women age 30-39. Birth intervals vary significantly with the child’s birth order. The lowest birth orders (2-3 births) show the least likelihood of being born soon after the previous birth. Birth intervals are markedly different depending on the survival status of the prior birth; the average interval is about 8 months longer in cases where the prior birth is alive than when that child has died (36 months and 28 months, respectively). 54 | Fertility Table 4.7 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since previous birth, according to demographic and socioeconomic characteristics, Turkey 2003 Number of months since previous birth Background characteristic 7-17 18-23 24-35 36-47 48+ Total Number of births Median number of months since previous birth Age of mother 15-19 (32.0) (28.8) (35.7) (3.5) (0.0) 100.0 23 22.8 20-29 16.8 17.6 27.7 13.7 24.3 100.0 1,333 30.2 30-39 9.0 9.9 19.9 13.2 48.0 100.0 1,194 44.6 40+ 9.8 7.9 16.6 10.7 55.1 100.0 169 56.1 Birth order 2-3 12.5 12.3 22.0 13.6 39.6 100.0 1,780 38.8 4-6 13.7 15.4 24.0 12.6 34.2 100.0 656 33.0 7+ 15.6 18.6 33.2 11.5 21.2 100.0 283 28.0 Sex of prior birth Male 13.7 13.7 22.2 13.6 36.8 100.0 1,352 36.2 Female 12.4 13.7 25.1 12.7 36.0 100.0 1,368 35.4 Survival of prior birth Living 12.1 13.6 23.9 13.1 37.3 100.0 2,565 36.2 Dead 29.0 15.5 19.5 14.8 21.2 100.0 154 27.6 Residence Urban 11.2 12.1 22.6 12.9 41.1 100.0 1,704 39.4 Rural 16.2 16.3 25.3 13.6 28.5 100.0 1.016 31.4 Region West 9.5 12.1 20.1 10.5 47.8 100.0 782 45.0 South 12.8 10.1 24.6 14.8 37.7 100.0 362 38.0 Central 11.3 12.0 18.9 13.2 44.5 100.0 497 41.2 North 12.3 12.9 22.1 14.7 38.1 100.0 175 37.8 East 17.5 17.5 29.2 14.5 21.3 100.0 903 29.3 NUTS 1 Region İstanbul 6.8 10.7 24.2 11.0 47.3 100.0 362 45.0 West Marmara 5.9 8.3 16.5 11.9 57.5 100.0 67 56.3 Aegean 13.8 11.1 12.3 9.3 53.6 100.0 215 50.4 East Marmara 14.4 18.1 18.8 12.7 36 100.0 202 34.4 West Anatolia 9.0 10.8 22.2 13.1 44.8 100.0 231 42.4 Mediterranean 12.8 10.1 24.6 14.8 37.7 100.0 362 38.0 Central Anatolia 10.3 12.4 19.8 11.6 46 100.0 149 41.6 West Black Sea 14.7 10.9 20.2 11.1 43 100.0 132 39.3 East Black Sea 9.1 15.5 20.4 18.4 36.6 100.0 96 39.0 Northeast Anatolia 16.3 15.4 24.4 15.6 28.3 100.0 142 32.4 Central East Anatolia 18.0 19.2 26.4 11.4 25 100.0 233 29.0 Southeast Anatolia 17.6 17.4 31.7 15.6 17.7 100.0 529 28.6 Education No educ./Prim. inc. 18.4 18.0 29.5 12.8 21.3 100.0 925 28.0 First level primary 11.3 12.2 21.7 12.6 42.2 100.0 1,389 39.7 Second level primary 3.9 9.2 19.2 16.3 51.4 100.0 151 48.7 High school and higher 8.6 9.1 15.5 15.7 51.1 100.0 254 48.6 Total 13.1 13.7 23.6 13.2 36.4 100.0 2,720 35.8 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. Note: Parentheses indicate that a figure is based on 25-49 unweighted cases. Fertility | 55 As Table 4.7 shows, the median birth interval in urban areas is 39 months, compared with 31 months in rural areas. There is 16-month difference between women in the western part of Turkey, who have the longest birth interval, and those in the eastern part of Turkey who have the shortest birth interval (45 months and 29 months respectively). Consistent with this finding, in all the NUTS 1 regions of the eastern part of Turkey, the median birth interval is nearly 30 months. There exists a clear association between the woman’s educational level and the average birth interval. The median birth interval is slightly over four years for women with high school or higher education as opposed to just over than the interval considered minimum safe for women with no education. 4.6. Age at First Birth The age at which childbearing begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. In many countries, postponement of first births has contributed greatly to overall fertility decline. Table 4.8 presents the distribution of women by age at first birth, according to their current age. For women under age 25 the median age at first birth is not shown because less than 50 percent of women in those ages had given birth at the time of the survey. The results in Table 4.8 suggest that there has been a steady rise in the age at first birth among women in Turkey. Women in younger cohorts are much less likely than older women to have given birth to their first child while they were in their teens. For example, among women age 45-49, 38 percent had become a mother before age 20, while only 28 percent of women age 25-29 had given birth to their first child before age 20. Overall, Table 4.8 shows that the median age at first birth ranges from a low of 21 years among women age 45-49 to 23 years among women age 25-29. These cohort changes that parallel with the increase in the median age at first marriage took place during the same period (see Chapter 7). Table 4.8 Age at first birth Percentage of women who gave birth by specific exact ages, and median age at first birth, by current age, Turkey 2003 Percentage who gave birth by exact age Current age 15 18 20 22 25 Percentage who have never given birth Number of women Median age at first birth 15-19 0.2 NA NA NA NA 94.3 2,003 a 20-24 0.4 7.8 21.1 NA NA 61.8 2,101 a 25-29 1.0 12.2 27.5 42.9 63.5 27.9 1,849 22.9 30-34 0.9 13.5 30.0 50.0 69.9 13.4 1,622 22.0 35-39 1.4 14.0 32.2 52.1 71.7 8.3 1,481 21.7 40-44 2.7 19.7 39.7 58.9 79.3 5.3 1,371 20.9 45-49 2.2 17.3 37.5 59.1 79.4 4.3 1,089 21.1 NA = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 4.9 presents trends in the median age at first birth across age cohorts for key sub-groups. The measures are presented for women age 25-49 years to ensure that half of the 56 | Fertility women have already had a birth. Overall, the median age at first birth is approximately 22 years for women 25-49. However, there are wide differences in the age at which women first gave birth among the various sub-groups. Urban women started childbearing one year later than their rural counterparts. On average, women in Eastern region had their first birth one and a half years earlier than women in the West region. Looking at the patterns by education within age groups, highly educated women had their first birth about two years later than women with less than a primary education. Table 4.9 Median age at first birth by background characteristics Median age at first birth among women 25-49, by current age and background characteristics, Turkey 2003 Current age Background characteristic 25-29 30-34 35-39 40-44 45-49 All women age 25-49 Residence Urban 23.2 22.2 22.1 21.1 21.4 22.1 Rural 22.2 21.7 21.0 20.6 20.4 21.1 Region West 23.3 22.3 22.3 21.4 21.4 22.2 South 23.0 22.3 22.9 22.2 22.2 22.4 Central 22.7 21.8 20.8 20.5 20.5 21.2 North 23.4 22.5 22.4 20.9 20.9 22.2 East 22.0 21.0 20.4 19.9 19.9 20.8 NUTS 1 Region İstanbul 23.5 22.8 22.0 21.0 21.5 22.3 West Marmara 24.0 22.0 21.5 21.8 21.0 22.0 Aegean 23.7 22.4 22.3 21.2 20.8 22.1 East Marmara 22.4 21.7 22.2 20.6 21.5 21.7 West Anatolia 23.0 21.7 21.5 22.1 21.2 22.0 Mediterranean 23.0 22.3 22.9 21.6 22.2 22.4 Central Anatolia 22.0 21.6 20.4 19.8 21.2 20.6 West Black Sea 22.7 22.6 22.0 21.5 20.2 21.8 East Black Sea 23.4 22.4 21.5 21.0 20.9 21.9 Northeast Anatolia 21.8 21.0 21.0 20.9 20.4 21.1 Central East Anatolia 22.7 21.4 19.9 20.4 20.1 20.9 Southeast Anatolia 21.7 20.7 20.4 19.5 19.2 20.6 Education No educ./Pri. incomp. 20.4 20.3 20.6 20.2 20.2 20.1 First level primary 21.6 21.4 21.1 20.9 20.9 20.2 Second level primary 22.2 22.8 22.3 22.1 22.1 22.3 High school and higher a 26.9 25.3 24.5 24.5 a Total 22.9 21.9 21.7 20.9 21.1 21.8 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. a Median ages at first birth for women with high school and higher education in the age groups 25-29 and 25-49 cannot be calculated because less than half of these women had a first birth before age 25. Fertility | 57 4.7 Teenage Pregnancy and Motherhood Teenage fertility is a major health concern because teenage mothers and their children are at high risk of illness and death. Childbearing during the teenage years also frequently has adverse social consequences, particularly on female educational attainment since women who become mothers in their teens are more likely to curtail education. Using information from the TDHS-2003, Table 4.10 shows the percentage of women age 15-19 who are mothers or who are pregnant with their first child. The overall level of teenage childbearing is approximately 8 percent, of which 6 percent already have given birth and 2 percent are pregnant with their first child. This percentage is slightly lower than that recorded in the TDHS-1998 when the proportion of teenagers who had begun childbearing was 10 percent. Table 4.10 shows that the proportion of women who have begun childbearing rises rapidly throughout the teenage years, from 1 percent among 16-year-olds to 3 percent among 17-year-olds, 8 percent among 18-year-olds, and 17 percent among 19-year-olds. There is no clear association between teenage childbearing and urban-rural residence. In terms of region, East region has the highest level of teenage childbearing (9 percent), while the North region has the lowest (3 percent). Surprisingly, Aegean region has the highest level of teenage childbearing with 13 percent. The level of teenage fertility is strongly associated with women’s educational level. The proportion of women age 15-19 who are pregnant or who have already given birth decreases from about 15 percent among women with less than primary education to 3 percent among women with at least high school education. 58 | Fertility Table 4.10 Teenage pregnancy and motherhood Percentage of teenagers 15-19 who are mothers or pregnant with their first child, by background characteristics, Turkey 2003 Percentage who are: Background characteristic Mothers Pregnant with first child Percentage who have begun childbearing Number of teenagers Age 15 0.0 0.2 0.2 388 16 0.9 0.4 1.3 425 17 3.5 1.8 5.3 410 18 8.2 3.2 11.4 412 19 17.2 3.5 20.7 368 Residence Urban 5.6 2.0 7.7 1,302 Rural 5.9 1.3 7.2 712 Region West 5.7 1.4 7.1 572 South 6.6 1.3 7.9 286 Central 6.1 1.4 7.5 501 North 2.0 0.7 2.7 147 East 6.0 3.1 9.1 505 NUTS 1 Region İstanbul 5.2 2.3 7.5 262 West Marmara 5.8 0.0 5.8 61 Aegean 11.5 1.2 12.7 195 East Marmara 2.8 0.9 3.7 166 West Anatolia 4.9 1.6 6.4 209 Mediterranean 6.6 1.3 7.9 286 Central Anatolia 4.0 0.6 4.7 129 West Black Sea 4.6 2.1 6.8 127 East Black Sea 0.5 0.0 0.5 75 Northeast Anatolia 3.8 2.3 6.1 98 Central East Anatolia 6.5 3.0 9.4 139 Southeast Anatolia 6.6 3.5 10.1 270 Education No educ./Pri. incomp. 10.6 3.9 14.5 302 First level primary 11.4 2.5 13.9 559 Second level primary 1.6 0.7 2.3 888 High school and higher 1.6 1.4 3.0 313 Total 5.7 1.8 7.5 2,003 Note: The sum of the absolute values does not add up to the total value in the last four variables due to use of the ever-married factors. Family Planning | 59 FAMILY PLANNING 5 Turgay Ünalan, İsmet Koç, and Sabahat Tezcan This chapter presents TDHS-2003 results relative to contraceptive knowledge, attitudes, and use. The chapter begins with an appraisal of the knowledge of different contraceptive methods before moving on to a consideration of past and current practice. For users of periodic abstinence and all ever-married women, knowledge of the ovulatory cycle is examined. For those relying on sterilization, the timing of method adoption is reviewed as well. Special attention is focused on source of contraception, informed choice, nonuse, reasons for discontinuation, and intention to use in the future. 5.1 Knowledge of Family Planning Methods Awareness of family planning methods is crucial in decisions on whether to use a contraceptive method and which method to use. Acquiring knowledge about fertility control is an important step toward gaining access to and then using a suitable contraceptive method in a timely and effective manner. To obtain data on contraceptive kowledge, TDHS-2003 respondents were first asked to name the means or methods by which couples could delay or avoid pregnancy. If the respondent failed to mention any of the methods listed in the questionnaire, the interviewer described the method and asked whether the respondent recognized it. Using this approach, information was collected for modern and traditional methods. Other traditional or ‘folkloric’ methods mentioned by the respondent were also recorded. No questions were asked to elicit information on depth of knowledge of these methods (e.g., on the respondent’s understanding of how to use a specific method). Therefore, in the analyses that follows, knowledge of a family planning method is defined simply as having heard of a method. Table 5.1 shows the level of knowledge of contraceptive methods among ever-married women and currently married women by specific method. Knowledge of at least one family planning method is almost universal among ever-married women and among currently married women. Almost all women interviewed in the survey know about at least one modern method. The most widely known modern contraceptive methods among ever-married women are the IUD (98 percent), the pill (98 percent), male condom (90 percent), female sterilization (90 percent), and injectables (82 percent) while the least known methods are female condom (14 percent) and emergency contraception (16 percent). Similarly, the most widely known modern contraceptive methods among currently married women are IUD (98 percent), the pill (98 percent), male condom (90 percent), female sterilization (90 percent), and injectables (83 percent) while the least known methods are female condom (13 percent) and emergency contraception (16 percent). Among traditional methods, withdrawal method is the most widely recognized one (94 percent for both ever-married and currently married women). The mean number of methods known is a rough indicator of the extent of knowledge of family 60 | Family Planning planning methods. On average, each ever-married woman and currently married woman know 8.5 methods. Table 5.1 Knowledge of contraceptive methods Percentage of ever-married women and of currently married women who know any contraceptive method, by specific method, Turkey 2003 Method Ever- married women Currently married women Any method 99.7 99.8 Any modern method 99.5 99.5 Female sterilization 89.7 89.8 Male sterilization 40.2 40.2 Pill 97.8 97.8 IUD 98.2 98.3 Injectables 82.1 82.5 Implants 43.0 43.3 Male condom 89.7 90.0 Female condom 13.5 13.4 Diaphragm 45.6 45.7 Emergency contraception 16.2 16.1 Any traditional method 97.7 97.7 Periodic abstinence 49.7 49.7 Withdrawal 93.7 93.9 Lactational amenorrhea method (LAM) 84.1 84.3 Folk method 8.2 8.1 Mean number of methods known 8.5 8.5 Number of women 8,075 7,672 Table 5.2 shows the percentage of currently married women who know any method of contraception and any modern method by backgound characteristics. Knowledge of any method and of any modern method is almost universal in all subgroups of background characteristics ranging from 98 to 100 percent. Family Planning | 61 Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women who know at least one contraceptive method and who know at least one modern method, by background characteristics, Turkey 2003 Background characteristic Knows any method Knows any modern method1 Number of women Age 15-19 98.4 98.0 237 20-24 99.8 99.5 1,019 25-29 99.9 99.8 1,435 30-34 99.9 99.9 1,423 35-39 99.6 99.6 1,333 40-44 99.8 99.2 1,223 45-49 99.8 99.3 1,001 Residence Urban 99.9 99.7 5,437 Rural 99.5 99.0 2,235 Region West 99.9 99.6 3,106 South 99.7 99.5 981 Central 99.6 99.4 1,770 North 99.8 99.8 561 East 99.7 99.3 1,253 NUTS 1 Region İstanbul 99.9 99.9 1,405 West Marmara 99.8 99.1 329 Aegean 99.5 98.6 1,079 East Marmara 100.0 100.0 669 West Anatolia 100.0 100.0 742 Mediterranean 99.7 99.5 981 Central Anatolia 99.6 99.4 446 West Black Sea 100.0 100.0 492 East Black Sea 99.6 99.6 275 Northeast Anatolia 99.9 99.5 234 Central East Anatolia 99.5 98.5 378 Southeast Anatolia 99.7 99.6 642 Education No education/Primary incomplete 99.1 98.2 1,664 First level primary 100.0 99.9 4,158 Second level primary 100.0 100.0 570 High school and higher 100.0 99.9 1,280 Total 99.8 99.5 7,672 1Female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, female condom, diaphragm, and emergency contraception 62 | Family Planning 5.2 Ever Use of Family Planning Methods The TDHS-2003 collected data on the level of ever use of family planning methods, which is defined as the use of a contraceptive method at any time during a woman’s reproductive years. To obtain these data, respondents were asked if they had ever used for each of the methods that they knew. Table 5.3 shows the percentages of ever-married and currently married women who have ever used any contraceptive method by specific method and age. Overall, the results indicate that 90 percent of both ever-married and currently married women have used a family planning method at some time. Across age groups, the lowest level of ever use of any family planning method is observed among ever-married and currently married women age 15-19, while after age 25 the percentages are around or above 90 percent. Table 5.3 Ever use of contraception Percentage of ever-married women and of currently married women who have ever used any contraceptive method, by specific method and age, Turkey 2003 Modern method Traditional method Current age Any Any modern Fe- male ster. Male ster. Pill IUD Inject- ables Im- plants Male con- dom Female con- dom Dia- phragm Emer- gency contra- cep- tion Any tradi- tional Perio- dic absti- nence With- draw- al LAM Folk Number of women EVER-MARRIED WOMEN 15-19 65.0 33.7 0.0 0.0 12.8 8.1 3.6 0.0 20.9 0.0 1.3 0.0 56.9 6.0 54.2 9.3 1.4 238 20-24 82.6 56.7 0.4 0.0 17.0 22.7 4.0 0.2 36.9 0.0 1.6 0.0 66.8 5.8 61.2 11.5 1.0 1,045 25-29 90.8 73.0 2.4 0.0 31.4 38.4 6.9 0.1 42.6 0.0 2.8 0.5 71.8 8.1 65.6 13.5 1.0 1,480 30-34 92.9 79.1 6.1 0.0 35.9 49.4 5.9 0.0 44.5 0.2 4.3 0.6 71.4 7.8 64.8 15.7 1.4 1,489 35-39 91.6 79.0 7.9 0.1 38.9 51.3 4.9 0.0 41.2 0.1 8.2 0.6 70.1 10.9 62.0 16.9 1.9 1,420 40-44 92.8 77.9 10.4 0.1 42.6 50.9 4.6 0.1 31.9 0.0 7.8 1.2 70.0 9.7 61.1 18.9 3.1 1,330 45-49 88.9 74.8 6.4 0.3 45.1 45.6 4.3 0.0 29.4 0.1 10.2 0.7 67.7 12.1 56.7 19.4 4.6 1,073 Total 89.6 73.0 5.6 0.1 34.8 42.8 5.2 0.1 37.8 0.1 5.7 0.6 69.5 9.0 62.0 15.8 2.1 8,075 CURRENTLY MARRIED WOMEN 15-19 65.0 33.8 0.0 0.0 12.8 8.1 3.6 0.0 21.0 0.0 1.3 0.0 56.8 6.0 54.1 9.3 1.4 237 20-24 82.6 56.6 0.4 0.0 16.8 22.8 3.9 0.2 37.0 0.0 1.6 0.0 67.2 5.7 62.1 11.4 1.1 1,019 25-29 91.3 73.6 2.4 0.0 31.7 38.6 7.1 0.1 43.2 0.0 2.9 0.5 72.2 8.2 66.0 13.7 0.9 1,435 30-34 93.7 79.7 6.2 0.0 35.6 50.2 5.8 0.0 45.1 0.3 4.4 0.5 72.5 7.7 65.8 15.9 1.4 1,423 35-39 92.0 79.3 8.3 0.1 38.5 51.8 5.1 0.0 41.8 0.1 7.9 0.5 71.2 10.6 63.3 17.3 2.0 1,333 40-44 93.4 78.1 10.9 0.1 42.5 50.8 4.6 0.1 32.6 0.0 8.2 1.2 70.6 9.4 62.4 18.9 3.2 1,223 45-49 89.8 75.3 6.5 0.3 45.5 46.1 4.3 0.0 30.1 0.1 9.9 0.7 69.4 12.4 58.3 19.5 4.3 1,001 Total 90.0 73.2 5.7 0.1 34.6 42.9 5.2 0.1 38.4 0.1 5.6 0.6 70.3 8.9 63.0 15.9 2.0 7,672 LAM = Lactational amenorrhea method More than 60 percent of women report ever use of withdrawal. Among modern method users of ever-married and currently married women, the IUD is the most commonly adopted (43 percent) followed by the male condom and pill (35 and 38 percent respectively). Experience using LAM (Lactational Amenorrhea Method) is reported by nearly 16 percent of women. Results related with LAM may be interpreted with caution since women may be confusing the method with traditional breastfeeding practices, despite the fact that the stress was made in the questionnaire to prevent such a confusion. Family Planning | 63 5.3 Current Use of Contraception The data on the current use of family planning is among the most important information collected in the TDHS-2003 since it provides insight into one of the principal determinants of fertility and serves as a key measure for assessing the success of the national family planning program. Table 5.4 shows the percent distribution of currently married women by current use of specific family planning methods according to age. Overall, 71 percent of currently married women are using contraception, with 43 percent depending on modern methods and 29 percent using traditional methods. The most widely used method is withdrawal (26 percent). Among modern methods, IUD is the most widely used method (20 percent) followed by male condom (11 percent). The use of contraceptive methods varies by age. Current use of any method is lower among currently married women age 15-19 (44 percent), rising to as high as 81 percent among currently married women in the 30-34 age group, and then dropping to 50 percent among currently married women age 45-49. The use of withdrawal peaks among women in the 40-44 age group (50 percent) while the highest level of IUD use (26 percent) is found among women age 30-34. Table 5.4 Current use of contraception Percent distribution of currently married women by contraceptive method currently used, according to age, Turkey 2003 Modern methods Traditional methods Current age Any Any modern Fe- male ster. Male ster. Pill IUD In- ject- ables Male con- dom Dia- phragm Any trad- itional Perio- dic absti- nence With- draw al LAM Folk Not currently using Total Number of women 15-19 44.3 16.9 0.0 0.0 4.0 6.2 0.3 6.4 0.0 27.5 1.8 24.8 0.8 0.0 55.7 100.0 237 20-24 59.2 31.4 0.4 0.0 5.0 15.8 0.7 9.2 0.4 27.9 0.6 25.7 1.5 0.1 40.8 100.0 1,019 25-29 74.8 47.2 2.4 0.0 7.4 23.1 0.4 13.4 0.5 27.6 0.7 25.7 0.9 0.2 25.2 100.0 1,435 30-34 80.9 51.6 6.2 0.0 5.9 25.6 0.5 13.0 0.5 29.3 0.8 27.7 0.6 0.2 19.1 100.0 1,423 35-39 80.7 51.2 8.3 0.1 4.3 25.1 0.6 12.0 0.9 29.4 1.0 27.8 0.3 0.4 19.3 100.0 1,333 40-44 76.4 44.6 10.9 0.1 3.3 19.2 0.1 10.0 1.0 31.8 1.6 29.5 0.1 0.6 23.6 100.0 1,223 45-49 49.9 25.8 6.5 0.3 1.3 11.1 0.0 5.7 0.9 24.2 2.1 20.9 0.0 1.2 50.1 100.0 1,001 Total 71.0 42.5 5.7 0.1 4.7 20.2 0.4 10.8 0.6 28.5 1.1 26.4 0.6 0.4 29.0 100.0 7,672 Note: If more than one method is used, only the most effective method is considered in this tabulation. LAM = Lactational amenorrhea method Table 5.5 shows that the current use of contraceptive methods varies according to residence, region, level of education, and number of living children. Currently married women living in urban areas are more likely to be using any contraceptive method than women in rural areas (74 percent and 65 percent respectively). Current use is lowest in the East (58 percent) and highest in the West and the Center (74 percent). With regard to NUTS 1 regions, current use is lowest in the Southeast Anatolia (56 percent) and highest in West Anatolia (79 percent). 64 | Family Planning Table 5.5 Current use of contraception by background characteristics Percent distribution of currently married women by contraceptive method currently used, according to background characteristics, Turkey 2003 Modern method Traditional method Background characteristic Any Any mod- ern Fe- male ster. Male ster. Pill

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