Zimbabwe - Demographic and Health Survey -1989

Publication date: 1989

Zimbabwe Demographic and Health Survey 1988 ¢.5D Central Statistical Office Ministry of Finance, Economic Planning, and Development @DHS Demographic and Health Surveys Institute for Resource Development/Macro Systems, Inc. Zimbabwe Demographic and Health Survey 1988 Central Statistical Office Ministry of Finance, Economic Planning, and Development Harare, Zimbabwe Institute for Resource Development/Macro Systems, Inc. Columbia, Maryland USA December 1989 This report presents the findings from the Zimbabwe Demographic and Health Survey (ZDHS). The survey was a collaborative effort between the Central Statistical Office and the Institute for Resource Development/Macro Systems, Inc. (IRD). The survey is part of the worldwide Demo- graphic and Health Surveys Program, which is designed to collect data on fertility, family planning and maternal and child health. Funding for the survey as a whole was provided by the U.S. Agency for International Development (Contract No. DPE-3023-C-00-4083-00) and the Government of Zimbabwe. In addition, special funding for the collection of information on the awareness of AIDS was provided by Family Health International through the AIDSTECH project. Additional information on the ZDHS can be obtained from the Central Statistical Office, Box 8063, Causeway, Harare, Zimbabwe. Additional information about the DHS Program can be obtained from DHS Program, IRD/Macro Systems, Inc., 8850 Stanford Blvd., Suite 4000, Columbia, MD 21045, USA (Telephone: 301-290-2800; Telex: 87775; FAX: 301-290-2999). PREFACE The Zimbabwe Demographic and Health Survey (ZDHS) was conducted as part of the worldwide Demographic and Health Survey (DHS) program which has been implemented in Africa, Asia, Latin America and the Middle East. Zimbabwe is one of fourteen countries from Africa, participating in the DHS program. The results from the national sample survey presented in this main report focus on basic demographic and health parameters, which are of interest to policy makers, administrators of health and family planning programmes, researchers and other users. The ZDHS was implemented by the Zimbabwe Government through the Central Statistical Office (CSO) in the Ministry of Finance, Economic Planning and Development (MFEPD). Technical assistance was received from the Ministry of Health (MOH); the Zimbabwe Family Planning Council (ZNFPC) and the Institute for Resource Development (IRD); financial support came from the United States Agency for International Development (U.S.A-I.D.) through the DHS program. The ZDHS was conducted immediately after the second round of the Intercensal Demographic Survey (ICDS). The principal objectives of the ICDS were to obtain data on population parameters including fertility and mortality, to update and revise the Zimbabwe Master Sample (ZMS) and to serve as a pilot study for the 1992 census. The objectives of the ZDHS were to collect more detailed information on: (1) fertility levels, trends and preferences, (2) family planning awareness, approval and use, (3) basic indicators of maternal and child health including infant mortality, and (4) various other topics related to family health. Planning for the survey commenced in 1987 when a working group composed of the CSO, MOH and ZNFPC was established to develop the survey content, sample design and fieldwork implementation procedures. The strong support of the MOH and ZNFPC, as well as various other government and donor organisations, facilitated the successful implementation of the project; warmest gratitude is extended to them. A special thanks is owed to the respondents interviewed in the survey for their patience and generosity with their time. Without their cooperation, the survey would not have been possible. G. M. Mandishona Director Of Census and Statistics Central Statistical Office TABLE OF CONTENTS Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v~i List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Map of Zimbabwe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx I BACKGROUND 1.1 Geography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.3 Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.4 Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.5 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.6 Family Planning Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1,7 Health Priorities and Programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.8 Objective of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.9 Organisation of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.10 Background Characteristics of the Women Surveyed . . . . . . . . . . . . . . . . . . . . . . . 10 2 MARRIAGE, BREASTFEEDING AND POSTPARTUM INSUSCEPTIBILITY 2,1 2,2 2,3 2,4 2.5 2,6 Current Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Sexual Activity Among Young Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Breastfeeding and Postpartum Insusceptibility . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Differentials in Breastfeeding and Postpartum Insusceptibility . . . . . . . . . . . . . . . . 23 3 FERTI I , ITY 3.1 3.2 3.3 3.4 3.5 3.6 Fertility Levels, Differentials and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Current Pregnancy . . . . . . . ' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Children Ever Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Children Ever Born and Age at Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Teenage Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 4 FERT I I JTY REGULAT ION 4.1 4.2 4.3 4.4 Knowledge of Contraceptive Methods and Providers . . . . . . . . . . . . . . . . . . . . . . 39 Other Obstacles to Family Planning Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Other Factors Facilitating Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Ever Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 4.5 Timing of First Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 4.6 Knowledge of Fertile Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 4.7 Current Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 4.8 Source for Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 4.9 Pill Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 4.10 Attitudes about Pregnancy and Reasons for Nonuse . . . . . . . . . . . . . . . . . . . . . . . 62 4.11 Intention to Use in the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 5 FERTIL ITY PREFERENC-'F~ 5.1 5.2 5.3 5.4 Desire for Additional Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Preferred Number of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Future Need for Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Need for Family Planning Among High Risk Groups . . . . . . . . . . . . . . . . . . . . . . 74 6 MORTAL ITY AND HEALTH 6.1 6.2 6.3 6.4 6.5 6.6 Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Maternal Care Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Immunisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Prevalence and Treatment of Diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Prevalence and Treatment of Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . 92 Nutrition Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 7 AIDS AWARENESS 7.1 7.2 7.3 7.4 7.5 Awareness of AIDS and Routes of Transmission . . . . . . . . . . . . . . . . . . . . . . . . 101 Knowledge of Preventive Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Blood Transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Sources of Information About AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Attitudes About AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Appendix A Appendix B Appendix C Sample Design and Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Sampling Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Survey Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 vi LIST OF TABLES 1.1 1.2 1.3 1.4 1.5 1.6 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Total Number of Schools and Teachers and School Enrolment (In Thousands) by Level of Education and Year, Zimbabwe, 1979-1988 . . . . . . . . . . . . . . . . . . . . . . . 3 Population Size and Annual Rate of Increase in the Population, Zimbabwe, 1900-1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Selected Demographic Indicators, Zimbabwe, 1982 and 1969 . . . . . . . . . . . . . . . . . . 4 Total Population, Area (in Square Kilometres), Population Density and Percent of Population Living in Urban Areas, by Province, Zimbabwe, 1982 . . . . . . . . . . . . . 5 Percent Distribution of Women 15-49 by Age, Urban-Rural Residence, Place of Residence, Level of Education and Religion, Zimbabwe DHS, 1988 . . . . . . . . . . . . 11 Percent Distribution of Women 15-49 by Level of Education, According to Age, Urban-Rural Residence, Place of Residence and Religion, Zimbabwe DHS, 1988 . . . 12 Percent Distribution of Women by Current Marital Status, According to Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Percent of Women 15-24 Ever and Currently Sexually Active and Percent of Never-married Women 15-24 Ever and Currently Sexually Active by Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Percent Distribution of Women by Age at First Marriage (Including Category "Never Married") and Median Age at First Marriage, by Current Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Median Age at First Marriage by Current Age, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . 20 Percent of Women Who Are Currently Attending School Full-time by Marital Status, According to Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . 20 Percent of Currently Married Women in a Polygynous Union by Age, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . 21 Percent of Births in the 36 Months Before the Survey Whose Mothers Are Still Breastfeeding, Postpartum Amenorrhoeic, Postpartum Abstaining and Insusceptible to Pregnancy, by the Number of Months Since Birth, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Median Number of Months of Breastfeeding, Postpartum Amenorrhea, Postpartum Abstinence, and Postpartum Insusceptibility, by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 vii 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 4.1 4.2 4.3 4.4 Total Fertility Rate for the Calendar-Year Periods 1985-1988 and 1982-1984 and for the Period 0-4 Years Before the Survey and Mean Number of Children Ever to Women 40-49 Years of Age, by Selected Background Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Age-Period Fertility Rates (per 1 000 Women) for Five-Year Periods Preceding the Survey by Age of Woman at Birth, and Cumulative Fertility (per Woman 15-34), Zimbabwe DHS 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Age-Specific Fertility Rates (per 1 000 Women) and Total Fertility Rates, Zimbabwe, 1969-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Percent of Women Who Were Pregnant the Time of the Survey by Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Percent Distribution of All Women and Currently Married Women By Number of Children Ever Born and Mean Number of Children Ever Born, According to Age, Zimbabwe DI-IS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Mean Number of Children Ever Born to Ever-married Women, by Age at First Marriage and Years Since First Marriage, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . 34 Percent Distribution of Women by Age at First Birth and Median Age at First Birth, According to Current Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . 35 Median Age at First Birth Among Women 25-49 by Current Age, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . 36 Percent of Women 15-19 Who Are Mothers or Pregnant with Their First Child by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . 37 Percent of All Women and Currently Married Women Who Know a Contraceptive Method and Who Know a Source For Contraceptive Information or Services Zimbabwe DHS, 1988 and Percent of All Women Who Know a Contraceptive Method, Zimbabwe RHS, 1984, by Specific Method . . . . . . . . . . . . . 40 Percent of Currently Married Women Who Know at Least One Modern Contraceptive Method and Who Know a Source for a Modern Contraceptive Method by Selected Background Characteristics, Zimbabwe DI-IS, 1988 . . . . . . . . . 41 Percent Distribution of Women Who Know a Contraceptive Method by Source Where They Would Obtain Method if They Wanted to Use It, According to Specific Method, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Percent Distribution of Women Who Know a Contraceptive Method by Main Problem Perceived in Using the Method, According to Specific Method, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 viii 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 Percent of Currently Married Women Who Know a Contraceptive Method by Husband's Approval of Family Planning, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Percent Distribution of Currently Married Women Who Know a Contraceptive Method by Number of Times Discussed Family Planning With Husband During the Year Before the Survey, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Percent of All Women Regularly Exposed to Mass Media by Type of Media, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . 46 Percent of All Women Who Heard or Read Any Information about Family Planning During the Month Before the Survey by the Source of Information, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . 47 Percent of All Women and Currently Married Women Who Have Ever Used a Contraceptive Method by Specific Method, According to Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Percent Distribution of Ever-married Women by Number of Living Children at Time of First Use of Contraception, According to Current Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Percent Distribution of All Women and Women Who Have Ever Used Periodic Abstinence by Knowledge of the Fertile Period During the Ovulatory Cycle, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Percent Distribution of All Women and Currently Married Women by Contraceptive Method Currently Used, According to Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Percent Distribution of Currently Married Women by Contraceptive Method Currently Used, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Percent of Currently Married Women by Contraceptive Method Currently Used, Zimbabwe DHS, 1988 and RHS, 1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Percent of Currently Married Women Currently Using Any Method and Any Modern Method, by Selected Background Characteristics, Zimbabwe DHS, 1988 and RHS, 1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Percent Distribution of Current Users by Most Recent Source for Method, According to Specific Method and Urban-Rural Residence, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 ix 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 5.1 5.2 5.3 5.4 Percent Distribution of Current Users of the Pill by Brand Used, According to Breastfeeding Status, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Percent of Current Users of the Pill Saying They Interrupted Use For At Least One Day During the Month Before the Survey by Source Where They Obtained the Pill, According to Urban-Rural Residence, Zimbabwe DHS, 1988 . . . . . . . . . . . . 60 Percent of Current Users of the Pill Who Interrupted Use For At Least One Day During the Month Before the Survey by Reason for Interrupting Use, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Percent Distribution of Current Users of the Pill by Action Taken If Pill Forgotten, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Percent Distribution of Non-pregnant Women Who Are Sexually Active and Not Using Any Contraceptive Method, by Attitude Toward Becoming Pregnant in the Next Few Weeks, According to Number of Living Children, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Percent Distribution of Non-pregnant Women Who Are Sexually Active and Not Using Any Contraceptive Method and Who Say that It Would Pose Problems if They Became Pregnant by Main Reason for Nonuse, According to Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Percent Distribution of Currently Married Women Who Are Not Currently Using Any Contraceptive Method by Intention to Use in the Future, According to Number of Living Children, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . 64 Percent Distribution of Currently Married Women Who Are Not Using Any Contraceptive Method but Who Intend to Use in the Future by Preferred Method, According to Whether They Intend to Use in the Next 12 Months or Later, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Percent Distribution of Currently Married Women by Desire for Children and Timing, According to Number of Living Children, Zimbabwe DHS, 1988 . . . . . . . . 68 Percent Distribution of Currently Married Women by Desire for Children and Timing, According to Age, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . 69 Percent of Currently Married Women Who Want No More Children by Number of Living Children, According to Selected Background Characteristics, Zimbabwe DHS 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Percent Distribution of All Women by Ideal Number of Children and Mean Ideal Number of Children for All Women and Currently Married Women, According to Number of Living Children, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . 71 5.5 Mean Ideal Number of Children for All Women by Age, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . 72 5.6 Percent of Currently Married Women Who Are in Need of Family Planning and Percent Who Are in Need and Who Intend to Use Family Planning in the Future by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . 73 5.7 Number and Percent of Women For Whom a Pregnancy Is Considered to Involve High Morbidity and Mortality Risk for Mother and Child by Risk Category, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 5.8 Percent Distribution of Currently Married Women in Young/Space or Old/Parity Risk Categories by Desire for Children and Timing, According to Risk Category, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 5.9 Percent Distribution of Currently Married Women in Young/Space or Old/Parity Risk Categories, by Contraceptive Use Status, According to Risk Category, Zimbabwe DHS, 1988 and RHS, 1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 6.1 Infant and Childhood Mortality for the Calendar Periods 1983-1988, 1978-1982 and 1973-1977, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 6.2 Infant and Childhood Mortality for the Calendar Period 1978-1988 by Selected Socioeconomic Characteristics of the Mother, Zimbabwe DHS, 1988 . . . . . . . . . . . 79 6.3 Infant and Childhood Mortality for the Calendar Period 1978-1988 by Selected Demographic Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . 80 6.4 Mean Number of Children Ever Born, Surviving and Dead, and Proportion Dead Among Children Ever Born by Age of Mother, Zimbabwe DHS, 1988 . . . . . . . . . . 81 6.5 Among Births in the Five Years Before the Survey, Percent Distribution by Person Providing Prenatal Care for the Mother and Percent Whose Mother Received a Tetanus Toxoid Injection, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 6.6 Among Births in the Five Years Before the Survey, Percent Distribution by the Person Assisting the Mother at the Delivery, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 6.7 Among Children Under Age 5, Percent with Health Card, Percent Who Are Immunised as Recorded on a Health Card or Reported by the Mother and, Among Children With Health Cards, Percent for Whom BCG, DPT, Polio and Measles Immunisations Are Recorded on the Health Card by Age (in Months), Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 xi 6.8 Among Children Under Age 5, Median Age (in Months) at Immunisation and Percent Given Vaccination at or Around Recommended Ages by Type of Immunisation, Zimbabwe, DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 6.9 Among Children 12-23 Months, Percent with Health Card, Percent Who Are Immunised as Recorded on a Health Card or Reported by the Mother and, Among Children With Health Cards, Percent for Whom BCG, DPT, Polio and Measles Immunisations Are Recorded on the Health Card by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . 87 6.10 Among Children Under Age 5, Percent Reported by the Mother As Having Diarrhoea in the Past 24 Hours and the Past Two Weeks by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . 89 6.11 Among Children Under Age 5 Who Had Diarrhoea in the Two Weeks Before the Survey, Percent Consulting a Health Facility, Percent Receiving Different Treatments as Reported by the Mother and Percent Not Consulting a Health Facility and Not Receiving Treatment, by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 6.12 Among Mothers of Children Under Age 5, Percent Who Know About Sugar/Salt/Water Solution by Level of Education, According to Urban-Rural Residence, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 6.13 Among Children Under Age 5, Percent Who Are Reported by the Mother as Having Cough in the Past Four Weeks, and, Among Children Who Suffered from a Cough, Percent Consulting a Health Facility, Percent Receiving Various Treatments and Percent Not Consulting a Health Facility and Not Receiving Treatment, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 6.14 Percent Distribution of Children 3-60 Months by Standard Deviation Category of Height-for-age Using the NCHS/CDC/WHO International Reference Population, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . 96 6.15 Percent Distribution of Children 3-60 Months by Standard Deviation Category of Weight-for-height Using the NCHS/CDC/WHO International Reference Population, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 6.16 Weight-for-height Standard Deviations Cross-tabulated by Height-for-age Standard Deviations, Using the NCHS/CDC/WHO International Standard Reference Population, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 6.17 Percent Distribution of Children 3-60 Months by Standard Deviation Category of Weight-for-age Using the NCHS/CDC/WHO International Reference Population, According to Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . 100 xii 7.1 7•2 7.3 7.4 7.5 Percent of Women Who Have Heard of AIDS and Who Think Someone Can Get AIDS from Various Sources by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Among Women Who Have Ever Had Intercourse, Percent Who Have Never Heard of AIDS and Percent Who Have Heard of AIDS But Have Done Nothing to Avoid AIDS, and, Among Those Doing Nothing to Avoid AIDS, Percent Giving Various Reason For Not Doing Anything, by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . 104 Among Women with At Least One Birth in the Last Five Years, Percent Receiving a Blood Transfusion with One or More Births by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Among Women Who Have Heard of AIDS, Percent Receiving AIDS Information from Various Sources by Selected Background Characteristics, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Among Women Who Have Heard of AIDS, Percent Who Hold Various Beliefs About Participation of a Person with AIDS in Society, Percent Who Think a Person with AIDS Should Not Donate Blood and Percent Who Think a Cure for AIDS Exists, by Selected Background Characteristics, Zimbabwe DHS, 1988 Appendix A A.1 Results of Household and Individual Interviews, by Place of Residence, • . 107 Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Appendix B B.1 List of Variable for Which Sampling Errors Are Presented, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 B.2 Sampling Errors for the Total Population, Zimbabwe DHS, 1988 . . . . . . . . . . . . . 122 B.3.1 Sampling Errors for the Urban Population, Zimbabwe DHS, 1988 . . . . . . . . . . . . 123 B.3.2 Sampling Errors for the Rural Population, Zimbabwe DHS, 1988 . . . . . . . . . . . . . 124 B.4.1 Sampling Errors for the Population 15-24, Zimbabwe DHS, 1988 . . . . . . . . . . . . . 125 B.4.2 Sampling Errors for the Population 25-34, Zimbabwe DHS, 1988 . . . . . . . . . . . . . 126 B.4.3 Sampling Errors for the Population 35-49, Zimbabwe DHS, 1988 . . . . . . . . . . . . . 127 B.5.1 Sampling Errors for the Population with No Education, Zimbabwe DHS, 1988 . . . 128 xiii B.5.2 Sampling Errors for the Population with Primary Education, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 B.5.1 Sampling Errors for the Population with Secondary or Higher Education, Zimbabwe DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 xiv LIST OF FIGURES 2.1 2.2 3.1 3.2 3.3 4.1 4.2 4.3 4.4 5.1 6.1 6.2 6.3 7.1 Percent of Young Adults Ever Sexually Active by Marital Status and Age . . . . . . . . 17 Duration of Breastfeeding and Postpartum Insusceptibility by Urban-Rural Residence and Level of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Cumulative Fertility (CEB) and Current Fertility (TFR) by Urban-Rural Residence and Level of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Age-Period Fertility Rates for Five-Year Periods Preceding the Survey . . . . . . . . . . 30 Percent of Women 15-19 Who Are Mothers or Pregnant With First Child . . . . . . . 37 Percent Who Had Fewer Than Two Children When They Began Using Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Current Use by Type of Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Current Use of Contraception by Method, ZRHS, 1984 and ZDHS, 1988 . . . . . . . . 56 Source for Contraceptive Methods Among Current Users by Urban-Rural Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Desire for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Percent Receiving Antenatal Care From Medical Personnel . . . . . . . . . . . . . . . . . 83 Immunisation Coverage Among Children 12-23 Months With Health Cards . . . . . . . 88 Percent Stunted Among Children 3-60 Months . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Percent of Women Having Heard About AIDS . . . . . . . . . . . . . . . . . . . . . . . . . 102 XV SUMMARY SUMMARY The Zimbabwe Demographic and Health Survey (ZDHS) is one of a series of surveys carried out by the Central Statistical Office (CSO) as part of the Zimbabwe National Household Survey Capability Programme. Conducted immediately following the second round of the Inter- censal Demographic survey in 1988, the objective of the ZDHS was to make available to policy- makers and planners current information on fertility and child mortality levels and trends, contra- ceptive knowledge, approval and use and basic indicators of maternal and child health. To obtain these data, a nationally representative sample of 4 201 women 15-49 was interviewed in the survey between September 1988 and January 1989. FERTILITY AND FAMILY PLANNING Fertility Levels and Differentials. The survey results suggest that Zimbabwe has been experiencing high and comparatively stable fertility levels, which have recently shown a decline. At current rates, a woman beginning her reproductive period at this time, will have an average of 5,5 births before her 45th birthday. Urban fertility is substantially lower than rural fertility; at current levels, a woman residing in an urban area will have an average of 4,1 births during her lifetime, while a woman living in a rural area will have 6,2 births. Fertility differentials by the woman's educational status are even more striking; at current rates, women with no formal education will have an average of 7 births and women with some primary education will have 6 births, while women with a secondary or higher education will have an average of less than 4 births. Marriage. Early marriage has been a factor supporting high fertility. The ZDHS results suggest that there is a trend toward delayed marriage, particularly among women with a secondary or higher education. More than half of the survey respondents married for the first time before their 20th birthday, with 9 percent saying that they first married before they were 15. The median age at first marriage among women 20-24 is nearly one year later than the median age for women 25-29, suggesting that the age at marriage has been increasing recently. Increasing educational attainment is related to the increase in the age at marriage. The median age at first marriage is more than 3 xix SELEC'I'ED FERTILITY AND FAMILY PLANNING INDICATORS Fertility Total Fertility Rate 1 Mean Number of Children Ever Born to Women 40-49 Marriage and Other Fertility Determinants Percent of Women 15-49 Married before Age 20 Median Age at First Marriage for: Women 20-24 Women 25-29 Median Duration of Breastfeeding (in Months) Median Duration of Postpartum Amenorrhoea (in Months) Median Duration of Postpartum Sexual Abstinence (in Months' Median duration of Postpartum Insusceptibility (in Months) Knowledge and Use of Family Planning Percent of All Women Knowing Any Method Percent of All Women Knowing Source for Information or Services Percent of Currently Married Women Ever Using Any Method Percent of Currently Married Women Currently Using Any Method: 1988 ZDHS 1984 ZRHS Percent of Currently Married Women Currently Using: Pill Other Modern Methods Traditional Methods Desire for Children and Need for Family Planning Mean Preferred Number of Children among All Women Percent of Currently Married Women: Wanting to Delay Next Birth for Two or More Years Wanting No More Children Percent of Currently Married Women Not Using Contraception and in Need of Family Planning to: Space the Next Birth Stop Childbearing 5,5 6,6 52,3 19,7 18,8 19,3 12,6 4,3 13,6 96,0 93,0 79,0 43,1 38,4 31,0 5,1 7,0 4,9 35,3 32,7 16,6 17,6 Based on births to women 15-44 during the period 0-4 years before the survey XX years later among women 25-49 who attended secondary school compared with women with no formal education (20,8 vs. 17,5). Improving educational opportunities for women will continue to be an important mechanism for encouraging later marriage. Currently, only two in five teenagers and one in twenty women 20-24 is attending school full-time. Breastfeeding and Other Proximate Determinants. By influencing the length of time following birth when a woman is naturally infecund and, thus, protected from a subsequent pregnancy, breastfeeding plays an important role in determining fertility levels. For some women, traditional practices of postpartum sexual abstinence may also contribute to lower fertility. The average (median) duration of breastfeeding is 19 months. As a result, a woman is protected from the risk of pregnancy for an average of almost 14 months following delivery. The long period of protection from pregnancy is largely due to the extended period of amenorrhoea following birth. The median duration of postpartum amenorrhoea (12,6 months) is almost three times that of postpartum sexual abstinence (4,3 months). Higher educational attainment and, especially, urban residence are associated with shorter average durations of breastfeeding and protection from pregnancy. Contraceptive Knowledge. The most important determinant of fertility decline is contraceptive use. Knowledge of contraceptive methods and service providers is a necessary precursor to use. Contraceptive knowledge is practically universal, with 96 percent of all women reporting that they have heard about at least one method. The most widely known modern method is the pill, followed by the condom, injection, IUD and female sterilisation. In addition to the widespread knowledge of modern methods, three in four women are familiar with at least one traditional method. Withdrawal is the most frequently recognised traditional method. Comparing knowledge levels in the ZDHS with those reported in the 1984 Zimbabwe Reproductive Health Survey (ZRHS), there has been increased recognition of all methods except vaginal methods and injection. Familiarity with a family planning service provider has increased since 1984, when only seven in ten women knew a place where they xxi could obtain contraceptive services. Currently, more than 90 percent are able to name a source for family planning services. Contraceptive Use. Experience with using family planning methods is widespread in Zimbabwe. The level of current contraceptive use is the highest reported among countries in sub- Saharan Africa. Among currently married women, 43 percent are currently using contraception, and an additional 36 percent have used a method in the past. Considering the method mix among current users, the pill (31 percent) is the most commonly used method. Current use of other methods is limited; 2 percent or less are using female sterilisation, the IUD, injection or the condom. The most prevalent traditional method, withdrawal, is used by 5 percent of currently married women. The current use rate represents an increase over that found in the 1984 ZRHS (38 percent). More importantly, today's users are much more likely to be relying on modern methods than they were four years ago. The urban-rural differential is fairly large; 52 percent are using in urban areas compared with 40 percent of rural women. Increasing educational attainment is directly associated with use; only one in three currently married women with no formal education is using, compared with half of all women with at least some secondary education. Almost all users rely on government-sponsored providers for contraceptive methods. Around two in five users obtained their method from a clinic operated by the Zimbabwe National Family Planning Council (ZNFPC) (13 percent) or one of the ZNFPC's community-based distribution workers (24 percent). Most other users rely on Ministry of Health (MOH) or local government clinics; only 4 percent obtained their method from a private doctor or pharmacy. Obstacles to Family Planning Use. To increase the level of contraceptive use in the future, it is important to understand why nonusers are not currently using family planning. The ZDHS results provide information on a number of potential obstacles to contraceptive use. Many women express concern about the potential adverse effect on their health of contraceptive use. For example, nearly 40 percent of women who know about the pill think that the main problem with the method is its effects on a woman's health. xxii For some women, disapproval of, or lack of interest in family planning, on the part of their husband, may be a barrier to contra- ceptive use. Overall, 15 percent of currently married women report that their husband disapproves of the use of family planning. For an even greater proportion of women there is little communication with their spouse about family planning; 31 percent never talked about family planning with their husband in the year before the survey. Additional insights into barriers to use come from the one in three nonusers for whom a pregnancy in the near future would pose major problems. Among these women, the principal reasons cited for nonuse are: infrequent sex, lack of access to methods, inconvenience of methods and opposition to family planning on the part of the woman or her husband. Fertility Preferences. Information on childbearing preferences of women provide insights into their future fertility behavior. The ZDHS results indicate that most women in Zimbabwe want large families and, as a result, the majority currently want more children. Women want on average 5 children. Three in four women want at least four children, and one in three wants six or more children. Six in ten currently married women want more children. Among women wanting more children, a strong interest in spacing the next birth is expressed; one-third of all currently married women want to wait at least two years before having another child. There is a growing desire to limit family size. One in three currently married women wants to have no more children. This represents a one-third increase in the proportion wanting to limit births since the 1984 ZRHS, when only one in four currently married women reported that she wanted no more children. Need for Family Planning. Women can be considered to be in need of family planning if they are not currently using a contraceptive method and either want no more births or want to postpone the next birth for two or more years. The ZDHS results indicate that, in spite of the high level of contraceptive use, there remain many women in need of family planning to avoid unplanned pregnancies. One-third of currently married women can be considered to be in need of contraception if they are to achieve their present child- bearing preferences. These women are almost evenly divided between those in need for stopping purposes (18 percent) and those in need for spacing purposes (17 percent). xxiii MATERNAL AND CH~ D HEALTH INDICATORS Mortality Infant Mortality Rate 1 Childhood Mortality Rate I Under Five Mortality Rate 1 Maternal Care Indicators Percent of Mothers of Recent Births: 2 Received Antenatal Care from Medical Personnel during Pregnancy Immunised against Tetanus Toxoid During Pregnancy Attended at Delivery by Medical Personnel Child Health Indicators Immunisation Coverage Percent of Children 12-23 Months Immunised as Reported on a Health Card or by the Mother Percent of Children With Health Cards Considered Fully Immunised Prevalence and Treatment of Childhood Illnesses Percent of Children Under Age Five with Diarrhoea in the Two-week Period Before the Survey Percent of Children with Diarrhoea: Consulted Health Facility Received Any Treatment Treated with Sugar/Salt/Water Solution Percent of Children with Cough in the Four-Week Period Before the Survey Percent of Children with Cough: Consulted Health Facility Received Any Treatment Nutrition Status Percent of Children 3-60 Months Considered: Wasted Based on Weight-for-height Stunted Based on Height-for-age Underweight Based on Weight-for-age 52,7 23,7 75,1 91,3 78,7 69,6 96,2 85,9 19,7 33,4 77,1 70,0 46,4 55,1 89,9 1,3 29,0 11,5 i Rates are for the calendar period 1983-1988 z Based on births in lhe five-year period before the survey xxiv More than one-half of those currently in need of family planning say that they intend to use contraception in the future. MATERNAL AND CHn~D HEALTH Infant and Child Mortality. The ZDHS results indicate that infant and child mortality levels have been declining. Significant differentials in mortality levels remain, however, among subgroups. The infant and child mortality rates for the period 1983-1988 are 53 and 24 deaths per thousand, respectively. Prospects for survival are much better for urban children than for rural children. For example, under-five mortality in urban areas is half that found in rural areas (55 vs. 99 deaths per thousand). Maternal education has a profound effect on child survival. Overall, under-five mortality varies from only 48 deaths per thousand for children of mothers with at least some secondary education to 125 for children whose mothers had no formal education. Higher mortality is observed for children of mothers under age 20 and of mothers nearing the end of their reproductive lives. There are significant differentials in mortality by the length of the preceding birth interval. Children born less than two years after an older sibling are almost twice as likely to die during infancy or early childhood as children born after an interval of two or more years. Maternal Care Indicators. The health care that a mother receives during pregnancy and at the time of delivery is important to the survival and well-being of both the mother and the child. The ZDHS results suggest that most Zimbabwean mothers have contact with medical personnel during pregnancy and at the time of delivery. For 91 percent of the births during the five-year period before the survey, the mothers received some form of antenatal care, provided by trained medical personnel (doctors and nurses). Almost 80 percent of births were to mothers who reported receiving a tetanus toxoid injection during pregnancy. Medical personnel attended 70 percent of births in the five years before the survey. XXV Child Health. The ZDHS also provides information on several major child health indicators, particularly the extent of immunisation coverage and the prevalence and treatment of diarrhoea and cough (a symptom of acute respiratory illness), which are major causes of child deaths in developing countries like Zimbabwe. lmmunisation coverage is quite good; 96 percent of children 12-23 months have received at least one immunisation--77 percent according to information on a Child Health Card and 19 percent according to the mother. Among children with health cards, 86 percent have been fully immunised. Twenty percent of children under five had diarrhoea during the two- week period before the survey. In one-third of the episodes, mothers consulted a health facility and, in 70 percent of the cases, they used a homemade sugar, salt and water solution to prevent dehydration (oral rehydration therapy). Knowledge of the solution as a treatment for diarrhoea is almost universal; 97 percent of mothers of children under five know about the solution. Mothers also seem to be aware of the importance of treating respiratory illnesses. Forty-six percent of children under five were reported to have had a cough during the four-week period before the survey. Almost half of the children experiencing cough were taken to a health facility. Two-thirds of the children were given cough syrup, and nearly one-quarter received oral antibiotics. Nutritional Status of Children. The ZDHS collected anthropometric measures for children 3-60 months, permitting an assessment of their nutritional status. Among the children measured, more than one in four was found to be stunted (very short in relation to age), an indication of chronic malnutrition. Fewer than one in fifty were wasted (very thin in relation to height). Around one in eight were underweight in relation to age. The nutritional status of the child is related to residence and the mother's education level. Rural children were twice as likely to be stunted as urban children, and children of mothers with no formal education are twice as likely to be stunted as those of mothers with secondary or higher education. The adverse effect of closely spaced births is apparent. Children born within two years of an older sibling are significantly more likely than other children to be stunted. xxvi AIDS. Acquired immune deficiency syndrome (AIDS), a result of infection with the human immunodeficiency virus (HIV), emerged in the 1980s as a major public health concern worldwide. Zimbabwe has an active program to disseminate information about AIDS. The ZDHS included questions to look at the effects of the campaign. In general, awareness of AIDS is widespread among women in Zimbabwe; 86 percent report having heard of AIDS. The chief sources of information about AIDS are pamphlets or posters (64 percent), radio (63 percent), health worker (51 percent) and newspapers (50 percent). The majority of women knowing about AIDS are aware that the disease is sexually transmitted and mention that those who have sex with many partners are at high risk. Most sexually active women have not taken steps to avoid getting AIDS. About one-third believe that they are not at risk. Among other frequently given reasons for taking no action are: (1) a belief that AIDS cannot be avoided and (2) lack of information about how to avoid the disease. xxvii Zimbabwe ZAMBIA WEST CENTRAL MOZAMBIQUE BOTSWANA MATABELELAND NORTH 8U/.4WAYO MIDLANDS MASVINGO MANICALANO MATABELELAHO SOUTH SOUTH AFRICA Chapter 1 BACKGROUND 1.1 GEOGRAPHY Zimbabwe lies north of the Tropic of Cancer and includes 391 thousand square kilometres between the Limpopo and the Zambezi Rivers. The country is landlocked, bordered by the People's Republic of Mozambique in the east, South Africa in the south, Botswana in the west and the Republic of Zambia in the north and northwest. It is part of a great plateau, which constitutes the major feature of the geography of southern Africa. Although only about five percent of Zimbabwe's land area ismore than 1500 metres above sea level, almost all of the country is more than 300 metres--and nearly 80 percent lies more than 900 metres--above sea level. About 70 percent of the country's surface area is made up of granite, schists and igneous rocks, which serve as the basis for Zimbabwe's mineral wealth. Soil types range from sandy/loamy in the high veld to sandy in the west. The sunny, temperate to hot climate attracts tourists and provides the basis for agricultural production, especially along the central ridge. Generally, temperature decreases and rainfall increases with altitude, ranging from the cool wet eastern highlands to the hot dry river valleys of the Zambezi, Limpopo and Save rivers. 1.2 HISTORY The African population, mainly of Bantu origin, entered what is now Zimbabwe during the 15th and 16th centuries. Beginning about the mid-19th century, a series of foreign invaders entered the region. From the west came the Portuguese for slaves; from the east, Arabs and Islamic Africans for ivory and slaves; and from the south, the English and the Dutch, mainly attracted by ivory. The invasions destabilised the established African communities. Spurred by the idea of establishing a trade route from the Cape of Good Hope to Cairo, and, thus, gaining control of the whole of Africa, white settlers fully established themselves in the region--then known as Southern Rhodesia--by 1890. Dissatisfaction with the white takeover on the part of the African population resulted in the uprisings of 1893 (Matabele) and 1896 (Matabele and Mashona). In spite of African resentment, white settlers continued to arrive, establishing rail communications, mining, especially gold and coal, and farming, principally along the high veld where communication lines were centered. In the 1920s, the country was annexed to the British Crown. Despite black opposition, the Land Apportionment Act, which reserved half of the land area (including the industrial and mining regions and the areas served by rail and road) for whites, was enacted in 1930. The Federation of the Rhodesias and Nyasaland was established during the period 1953- 1963. At this point, demands for self-determination on the part of blacks increased, further fueled by the granting of independence to both Zambia and Malawi. The refusal by the British to grant independence to the Rhodesian government without majority rule led to the Unilateral Declaration 1 of Independence (UDI) in November 1965. The struggle for majority rule continued and resulted in a protracted war, leading finally to the Lancaster House Talks and independence for Zimbabwe in 1980. 13 ECONOMY Zimbabwe has abundant natural resources, including 8,6 million hectares of potentially arable land and over 5 million hectares of forests, national parks and wild life estates. There are adequate supplies of surface and ground water for electric power, irrigation, and domestic and industrial use. Mineral resources are varied and extensive, including gold, asbestos, coal, nickel, iron, copper, lithium and precious stones such as emeralds. The economy is fairly diversified, with relatively developed commercial, industrial, mining and agricultural sectors. Manufacturing and agriculture are the leading producers for both domestic and export markets, with mining contributing more to export earnings than to the domestic economy. In addition to mining, major industries include food production, construction, chemicals, textiles, wood and furniture, transport-equipment and paper printing. Main agricultural exports include tobacco, maize, cotton, sugar and groundnuts. The agriculture sector has a well developed commercial component, co-existing with subsistence farming. The noncommercial (subsistence) agricultural sector is largely undeveloped, lacking essential physical and social infrastructure. Government development efforts lay increased emphasis on strengthening this sector, as reflected in the Government's Economic Policy Statement of Growth With Equity. 1.4 EDUCATION Education is considered a basic need and fundamental right. The formal education system begins with a seven-year primary cycle, which is basically free under the Universal Primary Education (.UPE) policy. It is followed by a secondary system with three levels: junior; middle/ordinary and upper/advanced. At the tertiary level, the University of Zimbabwe offers three- and four-year degree courses, plus postgraduate diplomas and masters and doctorate degrees in a number of subjects. Various postsecondary courses also are offered at teacher training, technical and agricultural colleges. The nonformal system includes afternoon/evening classes, study groups, private independent colleges, correspondence education, literacy campaigns and postliteracy programmes. Before independence, there were gross disparities at various levels in the education system, including an overall shortage of schools and inequities in educational opportunities between racial groups, males and females, rural and urban communities, and other subgroups. Efforts to overcome these inequities have resulted in a rapid expansion in the education system. As illustrated in Table 1.1, since 1979, there has been a substantial increase at all levels in the number of schools and teachers and the total enrolment. In addition, it is estimated that about 75 thousand people are participating in adult literacy classes and about 150 thousand in other nonformal education. Thus, about three million Zimbabweans are covered in either formal or nonformal educational programmes. Table 1,1 Total Number of Schoote end Teachers and School Enrolment t ln Thousands) by Level of Education and Year, zimbabwe, 1979-1988 Level of Education 1979 1983 1985 1988 Primary Nurrber of schools 2,4 4,0 4,2 4,5 Number of teachers 18,0 51,0 57,0 58,0 Enrolment 819,0 2044,0 2217,0 2221,0 Secondary Number of schools 0,2 0,8 1,2 1,5 Number of teachers 3,5 11,2 17,3 23,9 Enrolment 66,0 316,0 482,0 653,0 Higher Enrolment 8,5 18,4 -- 49,7 Source: Central Stat is t ica l Office, 198713 The increased attention placed on broadening educational opportunities has resulted in greater literacy. Immediately following independence, the 1982 census found that literacy 1 was 58 percent among the population 10 years and older (64 percent for males and 53 percent for females). The corresponding figure for the population 15 years and over was 62 percent (70 percent for males and 56 percent for females) (Central Statistical Office, 1985, p. 93). 1.5 POPULAT ION In Zimbabwe, censuses counting the full population were carried out only in 1961/1962, 1969 and 1982, but estimates of the size of the total population are available from the beginning of this century when the first census of non- Africans was undertaken. Table 1.2, which shows these estimates as well as the census figures, indicates that the average annual increase in the population has been 3 percent or more since the 1930s. According to the 1982 census, the total population in Zimbabwe had reached 7,6 million. There had been a decline in the European population. Ninety-eight percent of the 1982 population was of African origin compared to 95 percent in 1969 (Table 1.3). Table 1.2 Population Size and Annual Rate of increase in the Population, zimbabwe, 1900-1982 Annual Population Increase Year (in Thousands) (Percent) 1901 713 -- 1911 907 2,4 1921 1 147 2,4 1931 1 464 2,5 1941 2 006 3,2 1951 2 829 3,5 1961 3 969 3,5 1962 4 098 3,3 1969 5 134 3,3 1982 7 608 3,0 Source: Central s ta t i s t i ca l Off ice, 1987b and 1989 1 A person was considered to be functionally literate if he/she had completed Grade Three. 3 Table 1.3 Selected Demographic Indicators, Zimbabwe, 1982 and 1969 1982 1969 Indicator Census Census Total Poputati¢~ ( in Thousands) 7 608 5 130 Distr ibut ion by Ethnic Group (Percent): African 97,7 95,0 European 1,9 4~5 Asian 0,1 0,2 Co[oured 0,3 0,3 Distr ibut ion by Age Group (Percent)= 0-14 47,9 15-64 49,1 65 and over 3,0 Crude Birth Rate (CBR): Births per 1 ODD Population . ° . . 39,5 47 Crude Death Rate (CDR): Deaths per 1 DO0 Population Total 10,8 Hate 11,6 Female 10,1 Number of Mates per 100 Females in the Total Population Humber of Hales per 100 Females among Children Ever Born General Fer t iL i ty Rate (GFR)= Total Births per 1 000 Women 15-44 Total Fertility Rate (TFR): Total Births per W~n 15-44 96 101 175,8 5,6 2,8 Gross Reproduction Rate (GRR): Female Births per Wornan 15-44 Infant MortaLity Rate (1MR): Infant Deaths per 1 000 Births Total 83 Hate 93 Female 73 15 . . ° ° 6,6 101 (African) ° . Li fe expectancy at birth (e °) Total 57,4 50,8 Male 55,7 49,2 Female 59,1 52,5 Source: Central Stat is t ica l Office, 1969, 19871o and 1989 Table 1.4 Total Population, Area ( in Square Kilometres), Population Density and Percent of Population Living in Urban Areas, by Province, zimbabwe, 1982 Total population Population Percent Province ( in Thousands) Area Density(I) Urban Ranicatand 1 103 837 34 870 31,7 8,8 Nashonaland Central 560 847 27 28/, 20,6 9,1 Nashonatand East 1 496 500 24 934 60,0 58,8 Mashonaland West 854 098 60 467 14,1 20,4 Hatabeleland North 962 064 73 537 12,1 57,6 Natabeleland South 515 298 66 390 7,8 2,6 Nidlands 1 086 284 58 967 18,4 18,6 Nasvingo 1 029 504 44 310 23,2 6,2 Totat 7 608 432 390 759 19,5 26,7 Source: Central S ta t i s t i ca l Off ice, 1989 (1) Population per square kitometre At the time of the 1982 census, the crude birth rate (CBR) and the crude death rate (CDR) were estimated at 40 births per thousand population and 11 deaths per thousand popula- tion, yielding a natural growth rate of 29 per thousand. The corresponding figures from the 1969 census were higher, suggesting that both fertility and mortality levels declined over the period between the two censuses (Table 1.3). The comparatively high fertility prevailing in Zimbabwe has produced a young age structure; 48 percent of the 1982 census population was below age 15 while only 3 percent were elderly, i.e., 65 years and over. The population density increased from 13 per square kilometre in 1969 to 19.5 in 1982. Although much lower than the world average of 34 in 1982, it was higher than the average density for the African continent (16 persons per square kilometre) (Central Statistical Office, 1987b, p.16). The Zimbabwean population is largely rural. According to the 1982 census, only 27 percent of the population were living in urban areas, i.e., in localities with more than 2 500 inhabitants. More than half the urban population is found in the two largest cities, Harare and Bulawayo. There is substantial provincial variation in the degree of urbanisation, with the proportion of the population living in urban areas ranging from a high of 59 percent in Mashonaland East to 6 percent in Masvingo and less than 3 percent in Matabeleland South (Table 1.4). 1.6 FAMILY PLANNING PROGRAMME Family planning services have been available in Zimbabwe since 1953. With the establishment of the Family Planning Association (FPA) in 1965, responsibility for the previously uncoordinated family planning activities were consolidated in a single organisation. In the beginning, the FPA's work was confined to the white community, and contraceptives were not generally available to the African population. In 1966, however, the Minister of Health approved the provision of family planning services through government hospitals, thus, making them available to the African as well as European population. Government support for family planning was further evidenced in the decision in 1968 to provide an annual subsidy to the FPA. In Zimbabwe, the approach to family planning service delivery was initially largely clinic- based. Government family planning services were integrated into the maternal and child health care (MCH) delivery system at hospitals and clinics, and the prescription of hormonal contracep- tives was limited to medical and paramedical personnel. The FPA offered services primarily through urban clinics, although it operated some mobile units, which worked in neigh- boring rural areas . In 1967, to improve family planning services, the FPA began recruiting field educators. By 1970, 55 field educators were employed by the association, with 20 working in rural areas. At first, the field educator's role was to inform and motivate the population about family planning; clients wishing to use a method were referred to clinics. In 1976, however, the association obtained permission from the Ministry of Health for the field educators to distribute pills and condoms, forming the base for the current community-based distribution system. During the struggle for independence, unfortunately, the FPA came to be perceived as trying to limit births among the African population while encouraging births among the Europeans. In order to restore its effectiveness and to more fully integrate family planning into the national health service delivery system, the newly independent Government of Zimbabwe placed the Family Planning Association under the control of the Ministry of Health in September 1981, renaming it the Zimbabwe Child Spacing and Fertility Association (ZCSFA). In January 1984, the association officially became the Zimbabwe National Family Planning Council (ZNFPC), a parastatal organisation under the Ministry of Health. Through its network of clinics and the community-based distribution system, the ZNFPC continues to be the major provider of family planning services in Zimbabwe. ZNFPC clinics provide a full range of contraceptive methods, including the pill, IUD, injection, barrier methods and, at the main clinics in Harare and Bulawayo, voluntary female sterilisation. The ZNFPC also supplies contraceptives to 200 non-ZNFPC hospitals and clinics. These outlets, which are generally operated by the Ministry of Health or local government, provide pills and condoms, although some hospitals and clinics have facilities for performing sterilisations or inserting IUDs. The community-based distribution (CBD) system serves as the principal outreach mechanism for family planning service delivery in Zimbabwe and is the backbone of the ZNFPC programme. After they are selected by their communities, the distributors are trained to educate and motivate the population to use family planning, to supply clients with pills and condoms in their homes, and to refer women wanting to use other methods to clinics. The current work force of 600 distributors covers approximately 29 percent of the rural population in Zimbabwe (Zimbabwe National Family Planning Council, 1987). In addition to service delivery activities, the ZNFPC works with the Ministry of Education and Culture (formerly the Ministry of Primary and Secondary Education) through its Youth Advi- sory Services Unit to provide Family Life Education (FLE) to young people and their parents. The Training Unit operates two centres which offer training in family planning for both medical and lay personnel. The Information, Education and Communication (IE&C) Unit has responsibility for the development of a national programme of family planning education as well as for the production of information materials used by the ZNFPC units to educate and motivate the population to use family planning. 1.7 HEALTH PRIORH]E,S AND PROGRAM/JF-q Government priority in the health sector is to provide health services for all, hence the adoption of the slogan "health for all by year 2000". The emphasis is on the eradication of communicable diseases--the result of unsanitary living conditions, lack of a protected water supply and malnutrition. The latter health problem is rife in rural areas, where the diet is often not balanced. Activities currently being undertaken in the health sector to ensure that the priority of health for all is achieved include: establishment of rural health centres and the village health workers' programme; construction of hospitals, especially rural hospitals, and of rural medical stores; maintenance and upgrading of existing hospitals; construction of rehabilitation villages for those discharged from hospitals but in need of physiotherapy; improvement of facilities in mental hospitals; improving and expanding family planning facilities; construction of accommodation for medical students and staff. The National Health Service is established at four levels (primary, secondary, tertiary and quartenary (central)), with Primary Health Care (PHC) being regarded as the main vehicle through which health care programmes will be implemented. The main components of PHC include maternal and child health services; health education; nutrition education and food production; expanded programme on immunisation; communicable disease control; water and sanitation; essential drugs programme; and provision of basic and essential preventive and curative care. The majority of health services in Zimbabwe are provided by the public sector (Ministry of Health and local government, both in urban and rural areas). The health delivery system is graded into hierarchies of care, with each lower level referring difficult cases to the next higher level. At the bottom of the formal health care system are clinics and Rural Health Centres (RHC). These facilities which collectively are the primary care facilities, are staffed by nurses, nurse-midwives and environmental health technicians. The primary care facilities refer difficult cases to District Hospitals, which have both doctors and nurses. The district hospitals in turn refer patients to the Provincial Hospitals which ultimately refer to the Central Hospitals. Health service delivery is integrated so that every health facility offers the full range of available services at any time, i.e., both preventive and curative services are offered at the same time. Thus, a client will benefit from preventive services even if he/she originally visited the facility for curative services. For example, if a mother visits a clinic with a child to be treated for a cough, the staff will check on the immunisation status of the child and update it if necessary. They will also discuss family planning with the mother and start her on family planning if she is interested in using or update her supplies if she needs them. This is the so-called "supermarket 7 approach", where the whole range of health services is available under one roof at the same time. All health facilities are supposed to operate on this principle, which minimises unnecessary trips by clients who might otherwise have to come on special day for family planning, then on another day to immunise their child, etc. Under this approach, every health facility offers the full range of maternal and child health services (MCH), including family planning. Recognising that there are segments of the population with special needs and who are at greater risk, there is an MCH department in the Ministry of Health. Its special role is to devise programmes that will lead to improved health for mothers and children, again in an integrated manner. Part of the department's responsibility is to identify the priority health problems of mothers and children and identify strategies to alleviate those problems. There are efforts to improve the nutritional status of young children (under-fives) through regular growth monitoring and taking appropriate action for those with faltering growth. In conjunction with other organisations and Ministries, efforts are being made to ensure that working mothers spend more time with their children. Pregnant working mothers are entitled to 90 days maternity leave and to one hour breastfeeding time per day after their child is born. The proper weaning of children is also emphasised, with bottle feeding discouraged (and banned altogether in maternity wards). There is heavy emphasis on preventive services. Safe delivery is stressed, with the aim that every pregnancy end with a healthy mother and child. To achieve this objective, great emphasis is placed on ensuring that most deliveries occur in health facilities. In order to ensure that even those deliveries which occur at home take place under conditions of safety, however, there is also a programme to upgrade the skills of traditional birth attendants. Efforts directed toward the prevention of diseases through immunisation were greatly strengthened after independence, when the Zimbabwe Expanded Programme of Immunisation (ZEPI) was started. The programme aims to immunise all children against measles, diphtheria, whooping cough, neonatal tetanus, poliomyelitis and tuberculosis. ZEPI is a national programme operative in all areas of the country, both urban and rural. Diarrhoea and respiratory infections contribute significantly to ill-health in children. Special programmes have, therefore, been started to reduce suffering and deaths from these two diseases (the Control of Diarrhoeal Diseases (CDD) and Control of Acute Respiratory Infections (ARI) programmes). The concern in the CDD programme is prevent dehydration or to treat it early before it becomes severe. There is, therefore, great emphasis on teaching mothers about a salt and sugar solution, which they can prepare at home using their own ingredients and utensils and give their child at the start of a diarrhoea episode. The ARI programme aims at treating cases of res- piratory infection early before complications develop. There is, therefore, emphasis placed on recognition of signs of impending severity, both by mothers and primary health care workers so that help can be sought early. 1.8 OBJECTIVE OF THE SURVEY The ZDHS is one of a series of surveys undertaken by the Central Statistical Office (CSO) as part of the Zimbabwe National Household Survey Capability Programme (ZNHSCP). The ZDHS was conducted immediately after the second round of the Intercensal Demographic Survey (ICDS) in 1988. The main objective of the ZDHS was to provide information on: 8 fertility levels, trends and preferences; family planning awareness, approval and use; maternal and child health, including infant and child mortality; and other topics relating to family health. The survey was designed to obtain information on family planning use similar to that provided by the 1984 Zimbabwe Reproductive Health Survey (ZRHS) and data on fertility and mortality which would complement information collected in the two rounds of the Intercensal Demographic Survey (ICDS). In addition, participation in the worldwide Demographic and Health Survey project offered an opportunity to strengthen survey capability in Zimbabwe, as well as further comparative research by contributing to the international demographic and health database. 1.9 ORGANISATION OF THE SURVEY The ZDHS utilised a two-stage sample, which was self-weighting at the household level and nationally representative. It was drawn from the Revised Zimbabwe Master Sample (RZMS) on which the 1987 and 1988 ICDS samples were based. The RZMS is a subsample of the original Zimbabwe Master Sample constructed at the initiation of the ZNHSCP. Census enumeration areas (EAs) served as the first stage or primary sampling units and were selected with probability proportional to size, namely, the number of households in the 1982 census. The ZDHS sample included 167 of the 273 EAs from the RZMS, of which 114 were rural and 53 urban. The second stage units, households, were drawn systematically from the households residing in the selected EAs. A detailed description of the sample design is given in Appendix A, and sampling errors for selected variables are presented in Appendix B. Two questionnaires were used for the ZDHS, a household and an individual woman's questionnaire. The questionnaires were adapted from the DHS Model "B" Questionnaire, intended for use in countries with low contraceptive prevalence. A pretest was conducted, and the questionnaires were modified, taking into account the pretest results. The household and individual questionnaires were administered in Shona, Ndebele, or English, with these major languages appearing on the same questionnaire. Information on the age and sex of all usual members and visitors in the selected households was recorded on the household questionnaire and used to identify women eligible for the individual questionnaire. Eligibility for the individual interview was determined on a de facto basis, i.e., a woman was eligible if she was 15 to 49 years of age and had spent the night prior to the household interview in the household, irrespective of whether she was a usual member of the household or not. The individual questionnaire was used to collect information on the following topics: Respondent's background; Reproduction; Contraception; Health and breastfeeding; Marriage; Fertility preferences; Husband's background and women's work; Height and weight of children 3-60 months. 9 Copies of the questionnaires are reproduced in Appendix C. Training for the ZDHS was conducted in three phases, starting with a one-week session for the CSO staff serving as trainers and a core group of field personnel who were to be deployed as supervisors or field editors in the main survey. The main training session, involving 56 female trainees, took place for one month during August 1988 and covered such topics as the objectives and purpose of the ZDHS, general interviewing techniques, detailed instructions for completing the questionnaires and training in weighing and measuring children. Immediately following the main training, an additional anthropometric training course was held for the 14 field staff who were to act as measurers. CSO staff were primarily responsible for the training, with staff from ZNFPC conducting sessions on reproduction and contraceptive methods. Sessions on anthropometric measurement were held by staff from the Ministry of Health's Midlands Provincial Medical Office. Fieldwork was started on the 15th of September 1988 and was completed by the end of January 1989. The field staff included seven teams, composed of a supervisor, a field editor, four interviewers and a measurer. Each team was provided with a vehicle and a driver. Data entry and editing began in October 1988 and was completed in February 1989, two weeks after fieldwork ended. The initiation of data processing during the fieldwork allowed the errors that were detected to be communicated immediately to the field teams for corrective measures, thus improving the quality of the data. All data processing activities were carried out in Harare, by a team of five data capture operators under a data processing coordinator. The operators were responsible for office editing and coding, as well as for the entry of the questionnaires. The computer hardware consisted of three IBM-compatible micro-computers. The Integrated System for Survey Analysis (ISSA) software package, developed by IRD for the DHS programme, was used for all phases of the data entry, editing and tabulation. Range, skip and most consistency checks were performed during the data capture itself; only the more sophisticated consistency checks were done during secondary editing. 1.10 BACKGROLrND CHARACTER/STICS OF THE WOMEN SURVEYED Of the 4 789 households selected for the ZDHS, 4 337 were located in the field; of these, 4 107 households were successfully interviewed. Within the households successfully interviewed, 4 467 women were identified as eligible, and, among these eligible women, 4 201 women were interviewed. The overall response rate, which is the product of the household (95 percent) and individual (94 percent) response rates was 89 percent (see Appendix A). Table 1.5 presents the distribution of respondents by selected background characteristics. The data on age were obtained by first asking for the woman's date of birth and then her age at the last birthday, with the interviewer instructed to reconcile any differences. For most respondents the age data were complete; 90 percent were able to give both the month and year of birth, and 8 percent knew at least the year of birth. Reflecting the youthful age structure of the Zimbabwean population, a result of the past high fertility level, one in four of the respondents is in the 15-19 age group, and more than four in ten are under 25. Forty percent are between 25 and 39 years, and 14 percent are in the 40-49 group. 10 Table 1.5 Percent Distr ibut ion of Women 15-49 by Age, Urban- Rural Residence, Place of Residence, Level of Education and Religion, zimbabwe DHS, 1988 Background Number Characteristic Percent of Women Age 15-19 24,3 1 021 20-24 20,0 840 25-29 16,2 679 30-34 14,0 589 35-39 11,0 464 40-44 7,6 318 45-49 6,9 290 urban-Rural Residence Urban 33,5 1 407 Rural 66,5 2 794 Place of Residence ManicaLand 12,5 527 Mashonatand Central 6,9 288 Mashonatand East(1) 12,9 543 Mashonatand West 11,8 495 Matabetetand North(2) 4,5 189 Matabeleland South 6,7 282 Midlands 15,6 656 Masvingo 11,8 497 Harare/Chltungwiza 8,2 345 BuLawayo 9,0 379 Level of Education No Education 13,5 566 Primary 55,9 2 349 Secondary or Higher 30,6 1 286 Religion Christian 67,1 2 818 Spfritua( 20,2 848 Tradit ional 8,6 361 Other 2,7 113 No rel ig ion 1,3 56 Missing 0,1 5 Total 100,0 4 201 (1) Excludes Harare/Chitungwiza (2) Excludes gulawayo One-third of the women are from areas defined as urban or semi-urban, with the remainder (66 percent) from areas designated as rural, including communal lands, large-scale commercial farms, small-scale commercial farms and resettlement areas. Respondents living in the two largest cities (Harare/Chitungwiza and Bulawayo) account for 17 percent of the total sample and more than half of the urban sample. The proportion of respondents varies by province from a high of 16 percent in Midlands to 4 percent in Matabeleland North. 11 Most of the respondents have had some schooling; only 14 percent never received formal education, 56 percent have had some primary schooling, and 31 percent have achieved at least the secondary level. Two out of three women are members of major Christian denominations (e.g., Anglican, Methodist, Presbyterian, Dutch Reformed and Roman Catholic), while one in five belongs to a Spiritual church. A small minority (9 percent) adhere to tribal, animistic or other traditional beliefs. Table 1.6 looks at the association between educational attainment and other background characteristics. The younger generation is attaining higher education levels than the older. For Table 1.6 Percent Distribution of women 15-49 by Level of Education, According to Age, Urban-Rural Residence, Place of Residence and Religion, zimbabwe DHS, 1968 Background No Secondary/ Total Number Characteristic Education Primary Higher Percent of Women Age 15-19 2,5 47,7 49,8 100,0 1 021 20-24 7,0 42,4 50,6 100,0 840 25-29 18,0 61,9 20,2 100,0 679 30-34 17,3 65,4 17,3 100,0 589 35-39 17,5 68,8 13,8 100,0 464 40-44 29,6 61,0 9,4 100,0 318 45-49 28,3 64,8 6,9 100,0 290 Residence Urban 6,4 42,6 51,0 100,0 1 407 Rural 17,0 62,6 20,4 100,0 2 794 Place of Residence ManicaLand 14,2 64,3 21,4 100,0 527 Mashonatand Central 26,0 52,8 21,2 100,0 288 Mashonatand East(l) 15,1 57,5 27,4 100,0 543 Mashonaland West 19,8 58,8 21,4 100,0 495 HatabaleLand North(2) 25,4 56,1 18,5 100,0 189 MatabaleLand South 6,0 69,1 24,8 100,0 282 Midlands 11,9 52,0 36,1 100,0 656 Masvingo 12,5 62,4 25,2 100,0 497 Harare/Chitungwiza 3,8 43,2 53,0 100,0 345 Butawayo 4,7 40,6 54,6 100,0 379 Religion Christian 8,4 54,7 36,9 100,0 2 818 Spiritual 13,3 64,3 22,4 100,0 848 Traditional 42,9 50,4 6,6 100,0 361 Other 33,6 50,4 15,9 100,0 113 No Religion 35,7 37,5 26,8 100,0 56 Missing 40,0 60,0 0,0 100,0 5 Total 13,5 55,9 30,6 100,0 4 201 (1) Excludes Harare/Chitungwiza (2) Excludes BuLawayo 12 example, only 2 percent of the 15-19 age group never received a formal education, compared with 28 percent in the 45-49 age group. Among those who attended school, educational achievement is generally greater for younger women than older; 50 percent of the youngest cohort attended secondary school, compared with only 7 percent of the women in the oldest age group. There appears to have been an especially sharp increase in the percent of women achieving the secondary level in the recent past; one in two women under age 25 has had some secondary education, compared with only one in five women 25-29. Educational differences by residence are striking; the proportion of rural women without formal education is 17 percent, almost three times the urban rate. Moreover, among women who have attended school, those in urban areas are more likely than those in rural areas to have attained the secondary level. One in two women living in urban areas has attended secondary school, compared with only one in five rural women. There is also considerable variation in educational attainment by place of residence. The proportion having no formal education ranges from less than 5 percent in Harare/Chitungwiza and Bulawayo to 25 percent or more in Mashonaland Central and Matabeleland North. Those achieving at least the secondary level are most likely to be found in the two major cities--where half of the women have at least some secondary schooling--and Midlands--whe/'e 36 percent have attained the secondary level. Religious affiliation is associated with education. Women belonging to Christian or Spiritual churches are more likely to have attended school than women adhering to traditional beliefs. 13 Chapter 2 MARRIAGE, BREASTFEEDING AND POSTPARTUM INSUSCEPTIBILITY A number of factors influence the duration of exposure to the risk of pregnancy among women and, thus, determine fertility levels in a society. This chapter considers several of these variables, including marriage, breastfeeding, postpartum amenorrhoea and postpartum abstinence. Information on another major fertility determinant--contraceptive use--is presented in Chapter 4. 2.1 CURRENT MARITAL STATUS There are basically two forms of marriage in Zimbabwe--civil/church marriage and customary marriage. For the first type, the point of entry into the marital union is marked by a civil or religious ceremony. In customary marriages, however, it is difficult to say exactly when a couple is married since such marriages are preceded by the payment of a brideprice (lobola) which the husband can take a long time to complete paying. In the ZDHS, the concern was to identify couples who were cohabiting regardless of whether their unions had been formalised through either a civil/religious ceremony or through the payment of the brideprice. Therefore, the category "married" was defined to include cases where a couple was living together intending to have a lasting relationship, regardless of the formal status of the union. Any woman who reported herself as being in such a union was considered to be married. The remaining marital status categories include divorced/separated, widowed or never married. The joint divorced/separated category was used since it is difficult to distinguish between a divorce and separation in customary marriages. Thus, in any case where a woman had been married or lived with a man, but the couple was no longer cohabiting, she was assigned to the category divorced/separated. Table 2.1 shows the percent distribution of women in the sample by current marital status. Overall, 27 percent have never married, 63 percent are married, and 10 percent are divorced/ separated or widowed. The proportion never married decreases rapidly with age, from 80 percent of women 15-19 to 30 percent in the 20-24 age group. Less than 2 percent of women 25-49 have never married. Among ever-married (married, divorced/separated and widowed) women, the large majority, in all age groups, are currently married. As expected, widowhood is more common among older than younger women. The percent widowed increases from less than 1 percent among women under 25 to 10 percent among women 45-49. The proportion divorced/separated is fairly uniform across age groups, except for the youngest cohort; among women under 20, only 2 percent are divorced/separated, while in the 20-49 age groups, 8 to 11 percent are divorced/separated. 15 Table 2.1 Percent Distr ibution of Women by Current Marital Status, According to Age, Zimbabwe DHS, 1988 Current Marital Status Age Mumber Never- Divorced/ Total of married Married Widowed Separated Percent •ocen 15-19 80,2 17,6 0,0 2,2 100,0 1 021 20-24 28,5 61,1 0,5 10,0 100,0 840 25-29 6,8 82.3 1.8 9,1 100,0 679 30-34 2.5 85,4 2.5 9,5 100,0 589 35-39 1,5 86,9 3,7 8,0 100+0 464 40-44 0,9 79,6 8,8 10,7 10O.O 318 45-49 I,4 80,0 10,0 8,6 100.0 290 Total 27,0 62,9 2,5 7,6 100,0 4 201 2.2 SEXUAL At.,-IIVITY AMONG YOUNG ADULTS One area of concern to health workers is the problem of unplanned pregnancy among young unmarried women. The ZDHS obtained data on sexual activity from all women, regardless of their marital status. This information can be used to identify the proportion of young adults who have ever had sexual relations and those who are currently sexually active (i.e., have had sexual intercourse at least once in the month before the interview). Although respondents were interviewed alone and were assured that their answers were confidential, it is likely that there was some underreporting of sexual activity among these young women, especially never-married teenagers, either because of embarrassment or reluctance to disclose that they were sexually active. Although subject to reporting error, the questions on sexual activity are useful in defining i the population of young adults potentially exposed to the risk of pregnancy. Reproductive risk is likely to be greater for married women in this group than for young women who are currently sexual ly active but not involved in a stable relationship since the former group is more likely to have regular sexual relations. However, the economic and social burdens of childbearing are presumably greater for women who conceive and give birth to a child outside a marital union. Moreover, pregnancy and childbearing among women under age 18 have been shown to be associated with increased risk of morbidity and mortality for both mother and child. The first two columns of Table 2.2 show the proportion of all young adults who have ever had sexual intercourse and the proportion who are currently sexually active. Ever-married women are included among the ever sexually active, along with never-married women who report that they have ever had intercourse. The currently sexually active group includes all women who report having had intercourse at least once in the month before the survey. Overall, one in two young adult women have had sexual intercourse at some time, and around one in three is currently sexually active. Although the majority of young adults who have had sexual intercourse are ever-married, nearly one in four is never-married (Figure 2.1). Among teenagers, two in five women who have ever had sexual relations have never been married. 16 Table 2.2 Percent of gomen 15-24 Ever and Currently Sexually Active and Percent of Never-married Women 15-24 Ever and Currently Sexually Active by Age, Zimbabwe DHS, 1988 Age Among Never-married Number Among Women 15-24: Women 15-24: of Number Never- Ever Currently of Ever Currently married Sexually Sexually Women Sexually Sexually Women Active Active 15-24 Active Active 15-24 15-19 32,5 17,8 1 021 15.9 4.9 819 15 9,6 3,9 229 5.5 1.4 219 16 21,0 11,8 195 12.5 4.5 176 17 33,9 19,4 180 17.9 7.6 145 18 45,1 25,1 215 21.3 6,7 150 19 55,0 30,2 202 29.5 6.2 129 20-24 85,1 56,0 840 47.7 15.1 239 20 72,8 42,1 195 39.8 10.2 88 21 78,9 52,1 142 41.2 9.8 51 22 90+7 55,7 194 62.5 18.8 48 23 88,1 65,9 135 44.8 27.6 29 24 95,4 67,2 174 65.2 21.7 23 Total 56,2 35,0 1 861 23,1 7,2 1 058 Figure 2.1 Percent of Young Adults Ever Sexually Active by Marital Status and Age Percent 100 80 60 40 20 0 15-19 15 16 17 18 lg Age 20-24 [ m Never-married Women ~ Ever-married Women i Zimbabwe DHS 1988 17 Considering only never-married young adults, one in six teenagers has had sexual relations at some time, while, among women 20-24, one in two have had sexual intercourse (Table 2.2). The likelihood that a never-married young adult will have had sexual relations increases directly with age. Only 6 percent of never-married women age 15 report having ever had intercourse, while more than one-quarter of those age 19 and almost two-thirds of those age 24 have had sexual relations. Because premarital sexual unions are likely to be less stable than marital unions, it is not surprising that only about one-third of never-married young adults with sexual experience report that they are currently sexually active. It is also possible, however, that never-married women were willing to admit to having some sexual experience but reluctant to discuss recent sexual behavior. The results in Table 2.2 indicate that a significant proportion of young adult women in Zimbabwe become sexually active before marriage. Since for many of these young women a consequence of the premarital sexual activity will be unplanned pregnancy and/or early marriage, the findings highlight the need to continue support for special education and counseling services for youth. More information on the prevalence of teenage pregnancy is presented in Chapter 3. 2.3 AGE AT FIRST MARRIAGE For most women, the age at which they marry marks the beginning of regular exposure to the risk of childbearing. Increases in the average age at first marriage in a population are associated with the transition to lower fertility as the length of time the average woman spends at reproductive risk is reduced and, consequently, the number of children that she will bear over her lifetime declines. Information on age at first marriage was collected by asking each ever-married woman for the date (month and year) when she began living together with her first husband. If a woman could not remember the date of marriage, then she was asked how old she was when she first married. Among ever-married women, 77 percent were able to give both the month and year when they first married, 18 percent knew only the year and five percent were only able to report how old they were when they first married. In addition to recall problems, the data on age at first marriage may be affected by a tendency on the part of some women to report the date (age) when the marriage was officially registered rather than the date (age) when the couple first began living together. To the extent that such errors occurred, the information on age at marriage will be upwardly biased. Any analysis of the patterns in age at marriage must take into account the fact that the data on age at marriage are censored, i.e., they are available only for women who have ever married. Since never-married women in any age group will marry at later ages than those who are already married, the data on age at marriage from the ever-married group will give a downwardly biased picture of the pattern of age at entry into marriage for the age group. The effect of censoring is greatest in the youngest age groups where a significant proportion of women have never married. In describing trends and differentials in the age at marriage, the median is preferred to the mean, because it is not affected by censoring; the median is fixed once 50 percent of a group have married and, in contrast to the mean, will not increase as never-married women in the group continue to marry. 18 Table 2.3 Percent Distr ibut ion of Wo¢nen by Age at First Marriage (Including Category "Never Married") and Median Age at First Marriage, by Current Age, Zimbabwe gH$, 1988 Age at First Marriage Number Never Under 25 and Total of Median Age Married 15 15-17 18-19 20-21 22-24 Over Percent Women Age 15-19 80,2 3,7 12,1 3,9 0,0 O,O 0,0 100,0 1 021 -- 20-24 28,5 6,7 26,4 20,0 13,7 4,8 0,0 100,0 840 19,7 25"29 6,8 9,7 29,9 26,1 12,8 12,4 2,4 100,0 679 18,8 30-34 2,5 12,7 29,2 27,8 12,7 9,7 5,3 100,0 589 18,5 35-39 1,5 9,5 28,2 24,4 16,2 11,2 9,1 100,0 464 19,0 40-44 0,9 20,1 29,2 19,2 13,5 9,7 7,2 100,0 318 18,1 45-49 1,4 13,1 31,4 18,6 14,5 11,7 9,3 100,0 290 18,6 Iota[ 27,0 9,1 24,7 18,5 I0,4 7,1 3,3 I00,0 4 201 Note: Median age is defined as the age married. -- Omitted due to censoring by which 50 percent of the wocen have The ZDHS results indicate that women marry at a relatively early age in Zimbabwe. More than half of the respondents reported that they married for the first time before their 20th birthday, with 9 percent saying that they married before they were 15 (Table 2.3). Among women marrying after age 20, most married before their 25th birthday. Only 3 percent were 25 years or older when they married for the first time. There is some indication that the age at marriage has recently been increasing. The median age at first marriage among women 20-24 years, 19,7 years, is nearly one year higher than the median age for women in the 25-29 age group (18,8 years). The somewhat erratic variation in the median age among older cohorts is probably due to greater reporting error in these groups. Table 2.4 shows the variation in the median age at first marriage across age cohorts for women in various subgroups. No medians are presented for women 15-19 because more than 50 percent of this cohort have never married. For some subgroups, more than 50 percent of women 20-24 also have never married so that the median age at marriage for women 20-24 in these subgroups are not shown. In order to avoid the slight bias that the inclusion of women 20-24 from these subgroups would have on the median age for the subgroup as a whole, the medians presented in the total column in Table 2.4 are limited to women 25-49. The median age at first marriage for women 25-49 is slightly higher in urban areas (19,2 years) than in rural areas (18,4 years). Although the pattern is again somewhat erratic among older women, there is an upward trend in the age at first marriage among women under age 35 in both urban and rural areas. As expected, a woman's educational level also is strongly associated with her age at first marriage. The median age at first marriage for those with a secondary education is 20,8 years compared to 18,5 years for those with primary education and only 17,5 years for women who never attended school. The inverse relationship between age at first marriage and a woman's educational attainment is observed in all age cohorts. Within each educational status group, however, there is no clearcut trend in the age at first marriage across age cohorts. 19 Table 2.4 Median Age at F i r s t Marr iage by Current Age, According to Se lected Background character i s t i cs , Zimbabwe DHS, 1988 Current Age Background Total Characteristic 20-24 25-29 30-34 35-39 40-44 45-49 25-49 Urban-Rural Residence Urban -- 19,4 19,1 19,3 18,6 20.3 19,2 Rural 19,3 18,5 18,2 18,9 17,8 18,2 18,4 LeveL of Education No Education 16,7 17,2 17,3 18,9 16.7 17,8 17,5 Primary 17,9 18,5 18,5 18,8 18,1 18,3 18,5 Secondary or Higher -- 21,3 20,3 20,3 20,3 22,5 t 20,8 Tota l 19,7 18,8 18,5 19,0 3B,1 18,6 18,6 Note: Median age i s de f ined as the age by which 50 percent of the women have married. Median based on fewer than 25 cases -- Omitted due to censoring In summary, although the age at first marriage appears to be increasing, the ZDHS results show that many Zimbabwean women are marrying at an early age. In the absence of deliberate control of fertility, the longterm consequence of early marriage is higher lifetime fertility. The immediate consequence may be to limit educational and employment opportunities for many of the women who marry early. Table 2.5 shows the proportion currently attending school full-time among young adult women. Virtually none of the ever-married women under 25 were attending school full-time at the time of the survey. While early marriage may be the outcome of leaving school, many young adult women may drop out of school to marry. The results in Table 2.5 suggest that improving educational opportunities for young adult women may he an important step in encouraging later marriage. Overall, only two in five teenagers, and one in twenty women 20-24 is currently attending school full-time. Table 2.5 Percent of Women Who Are Currently Attending School Full-tima by Marital ~tatus, According to Age, Zimbabwe DHS, 1988 Never- Ever ° married married All Age gomen Women gecen 15-19 49,7 0,5 40,0 15 71,7 0,0* 68,6 16 5~,1 0,0" 46,2 17 44,1 0,0 35,6 18 44,0 1,5 31,2 19 23,3 0,0 14,9 20-24 13,0 2,5 5,5 20 17,0 6,5 11,3 21 21,6 2,2 9,2 22 4,2 0,0 1,0 23 10,3 1,9 3,7 24 0,0* 2,6 2,3 25-29 8,7 2,2 2,7 30-49 0,0 1,4 1,4 Total 39,0 1,7 11,8 * Percent based on fewer than 25 cases 20 2.4 POLYGYNY In many sub-Saharan African countries, the custom of polygyny, in which a husband takes more than one wife, is common. The effect that polygyny has on fertility levels is the subject of some debate, although it is generally assumed that the aggregate fertility of women in polygynous unions will be lower than that of women in monogamous unions because of reduced exposure to the risk of pregnancy. In Zimbabwe, polygyny is most prevalent in rural areas where the population remains more traditional in its approach to marriage and among members of some religions that believe a man may have more than one wife. Factors which contribute to a trend away from polygyny include the increasing cost of supporting more than one wife, especially in an urban setting and, as the population becomes more educated, the belief that the practice is old-fashioned. In order to gain some insight into the extent to which polygyny is currently practiced in Zimbabwe, married respondents in the ZDHS were asked if their husband had Other wives. Overall, one in six married women is in polygynous union (Table 2.6). Polygyny is more common among older than younger women; around 25 percent of women age 40 and over say that their husbands have more than one wife compared to less than 15 percent of women under age 30. The greater prevalence of polygyny among older than younger women may simply be a life cycle effect--as their wives grow older, husbands are more likely to take additional younger wives. However, the pattern may also be evidence that polygyny is becoming less common. Table 2.6 Percent of Currently Married Women in a Poiygynous Union by Age, According to Selected Background Characteristics, Zimbabwe DHS, 1988 Age Background Characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Urban-Rural Residence Urban 17,6 7,5 5,7 9,4 8,9 15,0 17,0 9,4 Rural 13,7 14,1 17,7 19,8 18,6 31,1 27,4 19,6 Level of Education No Education 23,5" 24,4 25,0 32,7 30,3 36,5 36,1 30,7 Primary 16,3 12,1 13,3 14,0 13,6 26,2 21,5 15,5 Secondary or Higher 9,2 8,3 5,6 6,9 7,4 O,O* 6,3* 7,2 Religion Christ{an 8,0 8,6 11,2 13,4 13,7 22,9 18,4 13,3 Spiritual 26,7 17,8 15,3 27,8 13,9 34,2 43,9 22,4 Traditional 17,6 11,1 21,3 11,4 38,5 43,3 25,0 22,8 Tota| 14,4 11,7 14,0 16,5 15,9 27,3 25,0 16,6 Percent based on fewer than 25 cases 21 Polygyny is clearly less prevalent among urban than rural women. Only around 10 percent of married women in urban areas are in a polygynous union compared with around 20 percent of rural women. A woman's educational level is strongly associated with the likelihood that her hus- band will have other wives. Among women who have never attended school, 31 percent are in a polygynous union, more than four times the rate for women with some secondary education. Religious affiliation also is related to the likelihood that the union will be polygynous; only 13 percent of women who are Christian are in such unions compared with 22 percent among women in the Spiritual or traditional categories. 2.5 BREASTFEEDING AND POSTPARTUM INSUSCEFrlBII.ITY Three other variables for which information is collected in the ZDHS--breastfeeding, postpartum amenorrhoea and postpartum sexual abstinence--play an important role in determining fertility levels by influencing the duration of the period following birth when a woman is not susceptible to the risk of another pregnancy. Table 2.7 presents cross-sectional data on the proportion of births whose mothers were found to be still breastfeeding, postpartum amenorrhoeic, abstaining and insusceptible. It should be noted that the information in Table 2.7 is birth-based rather than woman-based, i.e., a woman who had more than one live birth during the 36 months preceding the survey is included as many times as the number of births she had, with multiple births being treated as a single birth. Because the data are drawn from births at a single point in time rather than representing the experience of an actual cohort over time, the number of cases in the duration categories tend to be small. As a result, the proportions do not always decline in a steady fashion at increasing durations since birth as would be expected. To help minimise such fluctuations, the births are grouped in two-month intervals. In Zimbabwe, breastfeeding is almost universal, and most babies are breastfed for more than a year following birth. Table 2.7 shows that almost 90 percent of babies born about one year before the survey are still being breastfed and the proportion continuing to be breastfed is around 50 percent among babies age 18-19 months. Most children are fully weaned by their second birth- day; only 11 percent of babies age 24-25 months are still being breastfed. The period of postpartum amenorrhoea following birth, in which most women do not ovulate and hence are not at risk of pregnancy, is related to the duration and nature of breastfeeding. Generally, the longer a mother breastfeeds her child and the longer she waits before introducing supplements, the longer will be the period of amenorrhoea. The long duration of breastfeeding among Zimbabwean mothers is associated with an extended period of amenorrhoea. Table 2.7 shows that menstruation has not returned for more than 70 percent of mothers who are 6-7 months postpartum and around half the mothers 12-13 months postpartum are still amenorrhoeic. However, there is a rapid decline in the proportion amenorrhoeic after that point; only 20 percent of mothers 18-19 months postpartum are still amenorrhoeic, and almost all mothers whose babies are two years old or more have resumed menstruating. In many sub-Saharan countries, postpartum sexual abstinence is customary and may be enforced by cultural sanctions. A primary purpose of the custom is to delay the next pregnancy in order to ensure the full recovery of the mother after birth and the normal growth of the new baby. The results in Table 2.7 suggests that the practice of postpartum sexual abstinence is observed in Zimbabwe, but for a comparatively short time following birth. Around two-fifths of 22 Table 2.7 Percent of Births in the 36 Months Before the Survey Whose Mothers Are St i l l Breastfeeding, Postpartum Amenorrhoeic, Postpartum Abstaining and Insusceptible to Pregnancy, by the Number of Months Since Birth, Zimbabwe OHS, 1988 Months St i l t s t f t ( S t i l l Number Since Breast- Amenor- S t i l l Insuscep- of Birth feeding rhoeic Abstaining tibLe(1) Births Less than 2 95,0 88,7 82,5 91,2 80 2-3 94,9 78,8 56,8 87,3 118 4-5 91,8 70,9 31,8 75,5 110 6-7 92,2 73,5 27,5 77,5 102 8-9 89,4 61,S 10,6 62,5 104 10-11 89,8 50,9 13,9 55,6 108 12-13 87,6 49,6 7,1 51,3 113 14-15 81,7 43,5 9,2 48,9 131 16-17 73,4 30,3 7,3 34,9 109 18-19 52,1 18,8 6,3 22,9 96 20-21 33,3 13,1 1,0 14,1 99 22-23 16,1 2,7 7,1 9,8 112 24-25 11,4 0,8 3,8 4,5 132 26-27 6,5 0,0 5,8 5,8 138 28-29 3,9 0,8 0,8 1.6 126 30-31 2,8 0,0 2,8 2,8 106 32-33 1,7 0,0 3,4 3,4 119 34-35 O,O 0,0 0,0 0,0 97 Total 49,7 30,9 14,3 34,6 2 002 (1) Amenorrhoeic, abstaining or both the mothers whose babies are 2-3 months have resumed intercourse, and nearly three-quarters of women 6-7 months postpartum are no longer abstaining (Table 2.7). Among mothers whose babies are age one year, less than 10 percent are continuing to abstain from sexual intercourse. Table 2.7 also provides information about the proportion insusceptible to pregnancy because of either postpartum amenorrhoea or postpartum sexual abstinence (or both). Around 90 percent of mothers whose babies are under three months are not at risk of pregnancy, and half of the mothers whose babies are 12-13 months remain protected against pregnancy, either because they are amenorrhoeic and/or abstaining. The proportion who are insusceptible drops off rapidly.after this point, with only one-fifth of mothers whose babies are 18-19 months not at risk and less than five percent of mothers still insusceptible 24-25 months after delivery. 2.6 D ~ IN BREASTET_.EDING AND POSTPARTUM INSUSCEFI'IBII JTY Estimates of the median duration of breastfeeding, postpartum amenorrhoea and postpartum abstinence for various population subgroups are presented in Table 2.8, For each subgroup, the estimates are based on current status information (i.e., cross-sectional data on the proportion of births whose mothers were found to be still breastfeeding, amenorrhoeic, etc.) similar to that presented in Table 2.7. 23 Table 2.8 Median Number of Months of Breastfeeding, Postpartum Amenorrhoea, Postpartum Abstinence, and Postpartum ]nsuscept|bi l i ty, by Se[ected Background Characteristics, zimbabwe DHSo 1988 Number Background Breast- • Amenor - I nsuscep* of Characteristic feeding rhoea Abstinence tibitity(1) Births Age 15-29 19,0 12,6 4,3 14,0 1 226 30-49 20,0 12,6 4,5 13,0 776 Urban-Rural Residence Urban 17,5 9,6 3,7 10,3 517 Rural 20,1 13,4 4,7 14,2 1 485 Level of Education No Education 21,6 13,9 5,4 14,4 355 Primary 19,6 12,6 4,3 13,5 1 216 Secondary or Nigher 16,9 11,8 4,0 13,2 431 Iota[ 19,3 12,6 4,3 13,6 2 002 Note: The median number of months is based on the current status for each subgroup l ike that presented in Table 2.7 for the pop~tation as a who[e. (1) Amenorrhoeic, abstaining or both distr ibot lon The results in Table 2.8 again highlight the long average duration of breastfeeding in Zimbabwe. The median duration of breastfeeding is more than 19 months, and, as a result, the average mother is insusceptible to the risk of pregnancy for more than 13 months following delivery. The long period of insusceptibility is largely due to the extended period of amenorrhoea following birth. The median duration of postpartum amenorrhoea (12,6 months) is almost three times the median duration of postpartum abstinence (4,3 months). The median duration of breastfeeding is only one month shorter among births to younger mothers than among births to mothers age 30 and over (Figure 2.2). This is encouraging since a substantial decrease in the duration of breastfeeding among women under 30--which is commonly found as developing countries modernize--would increase the risk of unplanned pregnancies and shorter birth intervals among women in the key childbearing ages. Of more concern is the evidence that urban residence is associated with shorter median durations of breastfeeding and the other postpartum-related variables. The median duration of breastfeeding is nearly three months longer for rural births than urban births (20,1 vs. 17,3 months). The longer rural breastfeeding duration is associated with longer periods of both postpartum amenorrhoea and abstinence. As a result, the median duration of insusceptibility to pregnancy is nearly four months longer for rural than urban births (14,2 vs. 10,3 months). Breastfeeding duration is negatively associated with educational attainment of the mother, with the median duration for women with secondary education being five months shorter than that for women with no formal education. Differences in the median durations of postpartum amenorrhoea and postpartum abstinence across education categories are much smaller. As a result, 24 Figure 2.2 Duration of Breastfeeding and Postpartum Insusceptibility by Urban-Rural Residence and Level of Education RESIDENCE Urban Rural EDUCATION No Education Primary Secondary or Higher 0 5 10 15 20 25 Median Duration in Months L I I I Breastfeeding ~ Insusceptible i Zimbabwe DH$ 1988 the average mother with a secondary education becomes susceptible to the risk of pregnancy only about one month earlier than the average mother with no formal education. The patterns in Table 2.8 suggest that, currently in Zimbabwe, it is urban residence more than increasing educational attainment which is leading to behavior changes that significantly reduce the length of time a woman is insusceptible to the risk of pregnancy following a birth. The average duration of breastfeeding for urban births is, in fact, slightly longer than the median breastfeeding duration for births to mothers with a secondary education (17,3 months vs. 16,9 months). The median duration of postpartum amenorrhoea for mothers with secondary education is considerably longer than for urban mothers (1.1,8 months vs. 9,6 months). A tendency on the part of urban mothers, regardless of their educational level, to supplement earlier (and more oftener) than other mothers would help to explain this pattern. In order to maintain the comparatively long duration of postpartum insusceptibility among Zimbabwean women, it will be important to encourage all mothers--but particularly those in urban areas--to continue the traditional practice of extended breastfeeding. 25 Chapter 3 FERTILITY In this chapter, childbearing, information collected in the ZDHS is used to examine a number of topics, including past and present fertility levels and trends and the age at which women initiate childbearing. Attempts to arrive at reasonable fertility estimates within the scope of the ZDI-IS are important in view of the limited availability of reliable data on this topic for Zimbabwe. 3.1 FERTI I . r IY LEVELS, D I P P ~ AND TRENDS The fertility data from the ZDHS are based on responses to a series of questions designed to obtain information on the number and timing of births. All respondents were first asked about the total number of live births and surviving children. In addition, a full birth history was collected from each woman, including the name, sex, and date (month and year) of each live birth; the age at death for children who died; and whether or not living children were residing with their mother. Finally, as an indicator of future fertility, all women were asked if they were currently pregnant. Estimation of fertility levels from birth history can be affected by underreporting of the number of children ever born, while errors in the reporting of dates of birth can distort trends in fertility over time. In the ZDHS data, there exists the possibility of some underreporting of children, especially those who die immediately after birth. According to cultural practice, the death of such children should be ignored by the community at large and, in rural areas, children who die in early infancy are often buried without a funeral ceremony in unmarked graves. With regard to the reporting of birth dates, although the accuracy of the dates reported by the mother cannot be fully assessed in this report, one indicator of the quality of the information is the completeness of the dates; in the ZDHS, both the month and year of birth were obtained for 99 percent of the children. In considering the ZDHS fertility data, it is also important to note that errors due to omission of births or the misreporting of birth dates are likely to be less serious for time periods close to the survey date, which are the main focus in the analysis of the levels, trends and differentials in fertility presented in this chapter. Current and Cumulative Fertility Table 3.1 presents data on current and cumulative fertility patterns in Zimbabwe. The total fertility rate (TFR), which is a measure of current fertility, represents the average number of births a woman would have at the end of her reproductive life if she gave birth according to the age-specific fertility rates prevailing during a given period. The first two columns of Table 3.1 show total fertility rates for women 15-44 for two calendar periods, 1985-1988 and 1982-1984, while the third column shows the total fertility rates for the five-year period before the survey. The final column in Table 3.1 presents the mean number of children ever born (CEB) among women 40- 49. The latter indicator, which is a measure of cumulative fertility, is the product of the past childbearing behavior of these women who are nearing the end of their reproductive lives. The current trend in fertility in Zimbabwe can be assessed by comparing the TFRs for the two calendar 27 Tabte 3.1 Total Fer t i l i ty Rate for the Calendar-Year Periods 1985-1988 and 1982-1984 and for the Period 0-4 Years Before the Survey and Mean Number of Chitdren Ever Born to Women 40-49 Years of Age, by Setected Background Characteristics, zimbabwe DHS, 1988 Background Characteristic Mean Tatar Fertitity Rates (a) Number of Children 0-4 Years Ever Born 1985- 1982- Before to Women 1988(b) 1984 Survey Age 40-49 Urban-Rurat Residence ' Urban 3,86 5,33 4,13 5,20 Rura[ 6,06 7,28 6,23 7,15 Lever of Education NO Education 6,74 8,02 6,97 6,73 Primary 5,70 7,09 5,96 6,86 Secondary or Higher 5,68 4,63 3,84 4,50 Total 5,31 6,66 5,53 6,62 (a) Based on births to women 15-44 years (b) Includes period up to the survey date periods, while a comparison of the total fertility rate with the measure of completed family size provides a rough indication of the longterm trend in fertility levels. The total fertility rate for the five-year period preceding the ZDHS is 5,5 births per woman. A comparison of that rate with the mean number of children ever born per woman (6,6) suggests that fertility is declining. Much of that decline appears to be recent; the total fertility rate estimated for the period 1985-1988 (5,3 births per woman) is 21 percent lower than the rate of 6,7 births for the period 1982-1984. All of the fertility indicators in Table 3.1 point to higher rural than urban fertility. The TFR for the five-year period before the survey is 6,2 for rural women, two children higher than the urban rate. A similar differential is observed in the children ever born figures, although the level is one child higher in both groups, suggesting that fertility levels have been declining in both urban and rural areas (Figure 3.1). The apparent decline in fertility in both urban and rural areas suggested by a comparison of the mean children ever born with the five-year TFR is also observed in the rates for the two recent calendar periods. Fertility levels have declined sharply in both urban and rural areas, with the pace of the decline being somewhat faster in the urban areas. Differentials in the fertility indicators across educational status groups are even more striking than the urban-rural differentials. Looking at the TFRs for the five-year period before the survey, the rate among women who never attended school (7,0) is one birth higher than the rate for women with primary education (6,0) and three births higher than that for women with a secondary education (3,8). In contrast, there is almost no difference in the mean number of children ever born between the two lowest education groups, and the difference in the mean number between women who never attended school and women with some secondary education 28 Figure 3.1 Cumulative Fertility (CEB) and Current Fertility (TFR) by Urban-Rural Residence and Level of Education RESIDENCE Urban Rural EDUCATION No Education Primary Secondary or Higher TOTAL • 0 -4 yearsbefore the survey 0 1 2 3 4 5 6 7 8 Number of Births I - -TFR* I~W Children Ever Born i Zimbabwe DHS 1988 is only slightly more than two children. This suggests that the fertility decline in Zimbabwe. began with women who had at least some secondary education and only recently spread to women with less education. The current downward trend in fertility appears to be shared fairly equally by all educational groups, with the relative decrease in the TFR between the 1982-1984 and 1985-1988 periods being only slightly smaller for women with no education (16 percent) as compared to the other groups (20 percent). For many societies, the decline in fertility levels that accompanies mass schooling is not a direct consequence of a deliberate policy. Although it is difficult to predict with any certainty, further declines in fertility may be expected in the future in Zimbabwe as a consequence of the policy of improving educational opportunities for women. The governmental policy of universal primary education is likely to mean increasing participation of women in the educational system, which by lengthening the time spent in school, will lead to delayed marriage. Improved educational opportunities will also lead to increased employment opportunities for women in the productive sectors of the economy, again delaying marriage. Fertility Trends The fertility data presented in Table 3.1, which focus on current fertility levels, indicate that there has been a sharp decline in fertility recently in Zimbabwe. The birth history information in the ZDHS allows for a more extensive examination of the trend in fertility over a longer time period. Using the birth history data, Table 3.2 shows age-specific fertility rates for successive five- year periods preceding the survey. To compute the numerator for these rates, births were classified by the segment of time preceding the survey (e.g., 0-4 years, 5-9 years, etc.) and by the age of the mother at the time of the birth. The denominator is the number of women-years lived in the spec- 29 Table 3.2 Age-Period Fer t i l i ty Rates (per 1 000 Wocen) for Five-Year Periods Preceding the Survey by Age of Woman at Birth, end Cumulative Fer t i l i ty (per Woman 15-34), Zimbabwe DNS, 1988 Number of Years Preceding Survey Maternal Age 0-4 5-9 I0-14 15-19 20-24 25-29 30-34 15-19 109 143 165 150 153 178 (132) 20-24 255 300 305 312 305 (279) -- 25-29 257 293 298 295 (291) . . . . 30-34 228 261 270 (236) . . . . . . 35-39 168 208 i195) . . . . . . . . 40-44 88 (125) . . . . . . . . . . 45-49 (34) . . . . . . . . . . . . Cumulative Fer t i l i ty Ages 15-34 4,2 5,0 5,2 5,0 . . . . . . Note: Figures in parentheses are based on partiaLLy truncated information. -- Not calculated due to age truncation Figure 3.2 Age-Period Fertility Rates for Five-Year Periods Preceding the Survey Rate per 1 000 Women 35O 300 250 200 150 100 50 0 15-19 20-24 25-29 30-34 35-39 40-44 Age . . . . . 0 -4 Years 10-14 Years 5 -9 Years 15-19 Years i Zimbabwe DHS 1988 30 ified five-year age interval for each time segment. There is one obvious drawback in using these data for examining fertility trends; because women age 50 years and older who were bearing children during the time periods in question were not included in the survey, the rates for the older age groups in Table 3.2 become progressively more truncated further back in time. For example, rates cannot be calculated for the 45-49 age group for the period 5-9 years before the survey, because women who would have been 45-49 at that time were 50-54 at the time of the ZDHS and, consequently, not interviewed in the survey. Partially truncated rates are shown in parentheses. Looking at the age-period fertility rates in Table 3.2, it appears that fertility has been fairly stable over a 25-year period before the survey, decreasing only recently. The age-specific rates, which are depicted graphically in Figure 3.1, are remarkably similar, with a decline evident only in the most recent period. The highest rates are consistently observed for the 20-24 and 25-29 age groups. Another indicator of the essential stability in past fertility is the fact that the cumulative fertility rate for women 15-34 years varies only slightly, increasing from an average of 5,0 births per woman 15-34 in the period 15-19 years before the survey to 5,2 births in the period 10-14 years, before decreasing to 5,0 births in the period 5-9 years before the survey (Table 3.2). A significant decline in the fertility for this group is observed only in the most recent period, when the rate dropped to 4,2 births per woman. All age-groups appear to be contributing to the recent decline, although the decreases are proportionately greater for the youngest and oldest age groups (Figure 3.2). Table 3.2 relies on information collected in the ZDHS itself to examine trends in fertility over time. Another approach to looking at trends is to compare the ZDHS rates with those from other sources, including the 1969 Census, the 1982 Census ten-percent sample, the 1984 Zimbabwe Reproductive Health Survey and the 1987 Intercensal Demographic Survey. Table 3.3 presents the TabLe 3.3 Age-Specific Fer t i t i ty Rates (per 1 000 Wo~en) and Tots[ Fer t i t i ty Rates, Zin~ab~e, 1969-1988 ZDHS ZDHS Census Census ZRHS 1982- iCDS 198S- Age 1969 1982 1984 1984 1987 1988 15-19 79 91 131 129 69 103 20-24 272 258 289 299 213 247 25-29 304 253 299 307 240 247 30-34 257 225 263 273 214 219 35-39 218 165 220 214 168 160 40-44 145 93 92 111 84 86 45-49 7*5 38 11 41 36 TFR, 15-44 6,4 5,4 6,5 6,7 4,9 5,3 TFR, 15-49 6,7 5,6 6,5 6,7 5,1 5,5 Source: CentraL Stat is t ica l Office, 1985; Johansson, 1989; and Zimbabwe National Family Plenr~ing Council, 1985 31 age-specific and total fertility rates for all of these data sources. It is important to bear in mind, that except for the ZDHS, in which a birth history was collected, the rates from the various sources are based on questions concerning the timing of the last live birth. The census results also are generally more subject to omission of births or misreporting of birth dates than are surveys in which women of childbearing age are interviewed directly. The fertility estimates from the various data sources indicate that Zimbabwe has been experiencing high and comparatively stable fertility levels, which have only fairly recently shown a decline. However, in view of the different methodologies used to collect data in the censuses and the surveys, it would be unwise to draw any definite conclusion regarding fertility trends, until the estimates from the various data sources are further evaluated. What is certain is that, unless the apparent recent fertility decline continues, a Zimbabwean woman beginning her childbearing years in 1990 will have an average of five children by the time she reaches her fiftieth birthday in 2025. 3.2 CURRENT PREGNANCY Another indicator of current fertility is the proportion of women who are currently pregnant. One in eleven women interviewed in the ZDHS reported that she was pregnant at the time of the survey. This figure likely underestimates somewhat the actual proportion pregnant since some women in the early stages of pregnancy may be unaware or uncertain about their status. As shown in Table 3.4, the variation in the proportion pregnant by age follows a pattern similar to that of current fertility. The age group with the highest proportion currently pregnant is the 25-29 cohort (13 percent) while the 20-24 cohort has the second highest rate (12 percent); half of all currently pregnant women are found in these two groups. 3.3 CUH.nREN EVER BORN Table 3.4 Percent of Women Who Were Pregnant the Time of the Survey by Age, Zimbabwe DHS, 1988 Number Percent of Age Pregnant Women 15-19 5,7 I 021 20-24 12,1 840 25-29 12,8 679 30-34 I0,7 589 35-39 10,8 461+ 40-44 4,4 318 45-49 0,3 290 Total 8,9 4 201 Data on the number of children ever born to the women interviewed in the ZDHS are presented in Table 3.5 for all women and currently married women. These data reflect the cumulative outcome of the childbearing experience of women over their entire reproductive lives up to the point of interview. The results indicate that women 15-49 have had an average of 3,0 live births. The mean number of children ever born is somewhat lower than the means reported in the 1969 and 1982 censuses (3,5 and 3,1 births, respectively), again suggesting that fertility has been declining. As expected, since fertility levels have been high in the past, the number of children ever born increases rapidly with age. Women in their early twenties have had, on average, more than one birth. This increases to almost three children among women in their late twenties and to more than five children among women in their late thirties. Women 45-49 who are at the end of their childbearing years have had an average of almost seven births. The proportion who have never 32 Tabte 3.5 Percent Distr ibut ion of ALL WQ~en and Currentty Married Women By Number of Children Ever Born and Mean Number of Chitdren Ever Born, According to Age, Zimbabwe DHS, 1988 NLmVoer of Children Ever Born Age None 1 2 3 4 5 6 7 Number 10 or Tota[ of 8 9 More Percent Women Mean AlL Women 15-19 83,7 13,8 2,4 0,1 0,0 0.0 0.0 0.0 0,0 0,0 0,0 100.0 1 021 0,2 20-24 28,8 33,8 21,7 11,2 3,7 0,7 0,0 0,1 0,0 0,0 0,0 100,0 840 1,3 25-29 7,2 12,2 21,2 23,7 20,8 9,9 4,1 0,7 0,0 0,1 0,0 100,0 679 2,9 30-34 3,7 4,9 10,4 13,6 20,9 18.3 13.8 8.0 4,1 1,7 0,7 100,0 589 4,3 35-39 2,2 3,0 6,5 9,5 10,6 15,3 18,1 15,3 8,4 6,7 4,5 100,0 464 5,5 40-44 2,5 5,0 5,0 6,3 10,4 8.5 9,4 10.4 15,1 11,6 15,7 100.0 318 6,4 45-49 3,4 3,4 5,5 4,8 7,6 8,6 11,4 9,7 10,7 11,0 23,8 I00,0 290 6,9 Total 28,5 13,7 11,3 9,9 9,5 7,2 6,1 4,4 3,4 2,6 3,4 100,0 4 201 3,0 Currently Married Women 15-19 40,0 49,4 10,0 0,6 0,0 0,0 0,0 0,0 0,0 0,0 0,0 100,0 180 0,7 20-24 9,7 38,0 29,4 16,6 5,3 0,8 0,0 0,2 0,0 0,0 0,0 100,0 513 1,7 25-29 3,2 9,1 21,3 27,0 22,5 11,1 4,8 0,7 0,0 0,2 0,0 100,0 559 3,1 30-34 2,4 2,0 9,7 13,3 21,1 20,3 14,5 9,1 4,8 2,0 0,8 100,0 503 4,6 35-39 1,2 3,0 5,2 7,9 10,4 15,9 18,9 16,1 8,9 7,4 5,0 100,0 403 5,7 40-44 1,6 4,7 2,8 4,7 9,9 7,5 9,5 11,1 16,2 14,2 17,8 100,0 253 6,8 45-49 2,2 2,6 4,7 3,4 6,9 6,5 12,9 10,3 12,5 12,1 25,9 100,0 232 7~3 Total 6,3 14,2 14,2 13,5 12,9 10,1 8,7 6,4 4,9 4,0 4,9 100,0 2 643 4,1 had a child declines rapidly with age to 3 percent among women 45-49. This is within the expected 3-5 percent range and suggests that primary sterility is not a major problem for Zimbabwean women. One important goal of family planning programmes is to prevent infant and maternal deaths by assisting women to avoid high risk pregnancies. Evidence suggests that pregnancies among women who have already had five or more births are associated with increased mortality and morbidity for both the mother and the child. The results in Table 3.5 show that many Zimbabwean women, particularly those in the older age groups, are in this high parity risk category. Overall, more than one in four Zimbabwean women has had five or more births. By age, the proportion with five or more births increases from less than 10 percent among women under 30 to almost 50 percent in the 30-34 group. Among women age 35 and over, who already are at greater pregnancy risk because of their age, the proportion in the high parity risk group increases from nearly 70 percent in the 35-39 cohort to almost 75 percent among women 45-49. Many of these high parity women will go on to have additional births. According to current fertility patterns, women in the 30-34 cohort will have an average of two additional births before they complete childbearing, and women currently 35-39 may be expected to have, on average, one additional birth before reaching age 50. As discussed earlier, the recent fertility declines in age- 33 specific fertility rates have been greatest among women in the older age cohorts. Continuing fertility decline, which will limit births to older high parity women, will be an important factor in reducing health risks for both high parity women and their children. 3.4 C -~nR~ ~ BORN AND AGE AT FiKST MARRIAGE Table 3.6 shows the mean number of children ever born to ever-married women, controlling for age at first marriage and marital duration. The table permits an assessment of the relationship between age at marriage and the level of marital childbearing. The expectation is that women who marry early will bear more children since they will have more years of exposure to the risk of pregnancy than women who marry later. The population as a whole exhibits the expected pattern; the mean number of children ever born decreases from 5,2 among women who married for the first time before age 15 to 3,6 among women married at age 25 and above. To some extent this pattern is due to the fact that women marrying at young ages tend to be older, and, thus, have had more time to have children; the mean number of children ever born is directly associated with the duration of marriage, ranging from one child among women married less than five years to 7,5 children among women married 30 or more years. The results in Table 3.6 suggest that, once the effect of marriage duration is taken into account, age at marriage has no clear effect on the level of marital fertility. At shorter marriage durations, the mean number of children ever born generally increases with increasing age at first marriage. This pattern may reflect a higher level of premarital births among late-marrying women or shorter birth intervals among these women. At longer marriage durations, the pattern becomes more erratic, although there is some suggestion that women marrying later have fewer births. Table 3.6 Mean Number of Children Ever Born to Ever-married Women, by Age at First Marriage and Years Since First Marriage, zimbabwe DHS, 1988 Age at First Marriage Years Since First Under 25 or Marriage 15 15-17 18-19 20-21 22-24 More Total 0-4 0,9 1,0 1,1 1,1 1,3 1,9 1,1 5-9 2,5 2,7 2,7 2,7 2,6 3,5 2,7 10-14 4,0 3,9 4,1 4,1 4,0 4,9 4,1 15-19 5,7 5,6 5,4 5,4 5,6 4,0 5,4 20-24 6,4 6,6 6,3 6,5 5,5 5,9 6,3 25-29 6,7 7,6 7,2 5,9 5,7 7,0 30 or More 7,7 7,3 7,4 7,5 Total 5,2 4,2 5,8 5,5 3,2 3,6 4,0 34 3.5 AGE AT FIRST BIRTH Table 3.7 shows the percent distribution of women according to the age at first birth. As with the data on age at first marriage, the data on age at first birth are affected by censoring, i.e., they are available only for women who have already given birth. Since childless women in any age group will give birth at later ages, on average, than those who already have had a child, the information on age at first birth for those who have already given birth yields a downwardly biased picture of the average age at first birth for the group. The effect of censoring is greatest in the youngest age groups where a significant proportion of women have never had a birth. In describing trends and differentials in the age at first birth, the median is preferred to the mean because it is not affected by censoring. In addition to the problems of censoring, the data on age at first birth depend on accurate reporting of both the woman's birth date and the date of birth of the first child. Any misreporting of dates or underreporting of first births who later die will affect the results. Such errors are likely to be greatest in the case of births to older women. Finally, it is important to remember that the age at first birth is not necessarily the age at first pregnancy. Overall, somewhat more than one-quarter of women 15o49 have never given birth, with almost all of these women in the 15-24 age group. Nearly one-half had their first child before age 20, and one in four was under age 18 when she gave birth for the first time. Looking at the variation in the median age at first birth with the woman's current age, no clear trend is discernible. This may be the result of more frequent errors in the reporting of dates of birth among older women. Table 3.7 Percent Distr ibution of ~omen by Age at First Birth and Median Age at First Birth, According to Current Age, Zimbabwe DBS, 1988 Age at First Birth Median Number ABe at No Under 25 or Total of First Births 15 15-17 18-19 20-21 22-24 More Percent Women Birth Current Age 15-19 83,7 2,3 9,2 4,8 0,0 0,0 0,0 I00,0 1 021 -- 20-24 28,8 4,5 20,4 24,0 15,6 6,7 0,0 100,0 840 -- 25-29 7,2 4,9 24,7 28,7 20,2 12,4 1,9 100,0 679 19,5 30-34 3,7 6,3 26,5 26,5 19,2 12,1 5,8 100,0 589 19,4 35-39 2,2 8,2 17,5 27,2 20,0 16,2 8,8 100,0 464 19,8 40-44 2,5 11,6 27,7 17,6 17,3 13,5 9,7 100,0 318 19,2 45-49 3,4 11,4 22,4 20,0 15,2 14,8 12,8 I00,0 290 19,7 Total 28,5 5,7 19,6 20,0 13,6 8,9 3,7 100,0 4 201 Note: Median age i s def ined as e b i r th . -- Omitted due to censoring the age at which 50 percent of the women have had 35 Table 3.8 Median Age at First Birth Among Wo~en 25-49 by Current ABe, According to Selected Background Characteristics, zimbabwe DHS, 1988 Current Age Background Character i s t i c 25-29 30-34 35-39 40-44 45-49 Total Urban-Rural Residence Urban 19,8 19,6 19,7 19,4 21,2 19,8 Rural 19,3 19,2 19,9 19,2 19,3 19,4 Level of Education NO Education 18,4 18,4 19,7 18,0 19,7 18,9 Primary 19,3 19,3 19,7 19,1 19,4 19,4 Secondary or Higher 21,2 20,5 21,2 21,4 23,0* 21,2 Total 19,5 19,4 19,8 19,2 19,7 19,5 Note: Median age is def ined as the age at which 50 percent of the women have had a birth. * Median based on fewer than 25 cases Table 3.8 presents the median age at first birth for various subgroups. Because of the problem of censoring, the medians are shown only for women 25-49. Among all women 25-49, the median age at first birth is 19,5 years. The differential in median age at first birth between rural and urban areas is small (19,4 vs. 19,8). Greater differences in the median age at first birth are observed when educational level is controlled. The median age at first birth is 21,2 years for women with secondary or higher education compared with 19,4 years for women with primary education and 18,9 years for women with no education. As in the population as a whole, there is no discernible trend by age in the median age at first birth for any of the subgroups. 3.6 TF.FNAGE PREGNANCY The problems associated with teenage pregnancy are well-documented. Children born to very young mothers are less likely to survive following birth, and the mothers themselves are subject to much greater risks of illness and death associated with pregnancy than older mothers. As the last chapter showed, early marriage (and childbearing) are also associated with limited educational attainment for the mother. The ZDHS findings indicate that, largely due to the patterns of early marriage, teenage pregnancy has been the norm in the past, and it continues to be the pattern among young women. For example, the results in Table 3.7 for women 20-24 provide a picture of the extent of childbearing among teenagers in the early 1980s. Around one-half of these women gave birth before age 20, and one in four was under 18 years of age. 36 Table 3 .9 Percent of Women 15-19 Who Are Mothers or Pregnant with Their First Child by Selected Background Characteristics, Zimbabwe DHS, 1988 Percent Who Are: Number Pregnant of Background with First Women Characteristic Mothers Child 15-19 Age 15 3,1 1,3 229 16 6,7 3,1 195 17 14,4 4,4 180 18 19,5 10,2 215 19 38,6 3,0 202 Marital Status Never-married 4,6 1,3 819 Ever-married 63,7 16,8 202 Urban-Rural Residence Urban 10,2 4,3 323 Rural 19,1 4,4 698 Level of Education No Education 38,5 3,8 26 Primary 18,3 4,5 487 Secondary or Higher 13,2 4,3 508 Total 16,3 4,4 1 021 50 Figure 3.3 Percent of Women 15-19 Who are Mothers or Pregnant with First Child Percent 40 30 20 10 0 Total 15 16 17 18 lg None Prim. Sec.÷ AGE EDUCATION m Mothers U Pregnant w/lst Child / Zimbabwe DH$ 1989 37 Table 3.9 looks at patterns of pregnancy and childbearing among women currently in the teenage years. Since some teenagers who have not yet given birth will go on to have a child before their 20th birthday, these data do not represent the complete childbearing experience of today's teenagers. As a result, they cannot be compared with information from women 20-24, all of whom have completed the teenage period. The information is important, however, because it highlights the substantial numbers of teenagers who have already had a birth or are pregnant with their first child. Table 3.9 shows that 16 percent of teens are already mothers and 4 percent are pregnant with their first child. Among those under 18, for whom early childbearing presents the greatest risk, 10 percent are currently pregnant with or have had their first child. Most teenage mothers have married, but around one in 20 unmarried teens has had a child or is currently pregnant with her first birth. One in four rural teenagers is pregnant or already a mother compared with one in seven urban teens. The small number of teenagers who have never attended formal school are twice as likely as to be mothers as teenagers with some schooling (Figure 3.3). Among teens with some formal schooling, the proportion who have a child is somewhat higher for those with only primary education (18 percent) compared with those with secondary education (13 percent). The proportion currently pregnant with the first child varies little with educational level. 38 Chapter 4 FERTILITY REGULATION This chapter focuses on issues relating to the use of contraception. Knowledge of Contraceptive methods and service providers, a necessary precursor to use, is reviewed first. Obstacles to use, including perceived problems in using methods and husband's disapproval, are discussed. Information on other factors which may facilitate use, including discussion of family planning by the couple and exposure to information about family planning through the media is provided. Attention then turns to the levels, trends, and differentials in contraceptive use in Zimbabwe. Finally, consideration is given to reasons for nonuse and intention to use in the future. 4.1 KNOWl.I~I3GE OF CONTRACEPTIVE METHODS AND PROVIDERS Levels, Trends and Differentials Knowledge of family planning methods and service providers are preconditions to use. In the ZDHS, data on knowledge of family planning methods were obtained by first asking respondents to name the ways a couple can use to delay or avoid a pregnancy or birth. If a respondent did not spontaneously mention a particular method, the method was described by the interviewer and the respondent was asked if she recognised it. Descriptions were included in the questionnaire for eight modern methods (pill, IUD, injection, diaphragm, condom, female sterilisation, male sterilisation and foam/jelly/foaming tablets) and two traditional methods (periodic abstinence (safe period) and withdrawal). In addition, other folk or traditional methods mentioned by the respondents were recorded. Finally, for all modern methods that the woman recognised, she was also asked where she would go to obtain the method if she wanted to use it. If the respondent recognised periodic abstinence, she was asked where she would go to obtain advice about the method. As Table 4.1 indicates, knowledge of at least one modern method of family planning is practically universal, with 96 percent of all women and 99 percent of currently married women reporting that they have heard about at least one method. Among all women, the most widely known modern method is the pill (94 percent), followed by the condom (77 percent), injection (62 percent), the IUD (52 percent), and female sterilisation (50 percent). Other modern methods (diaphragm, foam/jelly/foaming tablets and male sterilisation) were recognised by less than one- fifth of the women. In addition to the widespread knowledge of modern methods, three in four Zimbabwean women are familiar with at least one traditional method. The most widely known traditional method is withdrawal (63 percent). Comparing knowledge levels in the ZDHS with those reported in the 1984 Zimbabwe Reproductive Health Survey, there is increased recognition of all methods except vaginal methods and injection. The small decrease in the proportion of all women knowing about injection probably reflects the fact that injection has not been widely available since restrictions were placed on its use in the early 1980s. Some of the gains in method recognition may be attributed to differences 39 Table 4.1 Percent of Al l Women and Currently Married Women Who Know a Contraceptive Method and Who Know a Source For Contraceptive Information or Services Zimbabwe DHS, 1988 and Percent of Al l Women Who Know s Contraceptive Method, Zimbabwe RHS, 1984, by Specific Method 1988 ZDHS Know Method Know Source 1984 ZRHS Current [y Current Iy Know Method Contraceptive Al l Married Al l Married Method Women Women Women Won~n Al l Women Any Method 96,3 98,7 93,0 96,5 82,8 Any Modern Method 95,4 97,8 92,1 96,0 NA Pill 93,6 97,0 89,4 94,6 80,5 IUD 51,6 59,1 45,0 52,6 40,2 Injection 62,2 72,4 56,5 66,2 67,6 Diaphragm 14,0 14,5 11,5 12,4 NA Foam/Jeliy/Foaming Tablets 13,5 14,9 12,3 13,6 17.4(a) Condom 76,7 80,3 66,0 72,5 48,3 Female Ster i t i sat ion 49,7 54,6 46,3 51,3 40,0 Male Ster i t i sat ion 16,4 17,6 14,5 15,5 10,8 Any Tradit ional Method 75,3 86,8 47,6 51,8 NA Periodic Abstinence 28,1 27,2 25,2 24,5 20,4 Withdrawal 63,4 79,2 56,1 Other(1) 34,2 40,6 31,9 37,8 NA Number of Women 4 201 2 643 4 201 2 643 2 574 Source: Zimbabwe Reproductive Health Survey, unpublished data, NA = Not available (1) Includes herbs and other folk methods (a) Includes diaphragm as welt as foam/jelly/foaming tablets in the way in which the data were collected in the two surveyS. ~ However, the substantial increase in the proportion of women knowing about the condom is likely owed to the publicity given to the condom as one of the principal ways of preventing the transmission of the AIDS virus (See Chapter 7 for a discussion of AIDS awareness among ZDHS respondents). Awareness of a source where modern contraception can be obtained also appears to have improved since 1984 when only seven in ten women knew a place where they could obtain contraceptive services (Zimbabwe National Family Planning Council and Westinghouse Public Applied Systems, 1985, Table 6.6). Currently, more than 90 percent of all women are able to name a source where family planning services or information are available. Considering specific methods, 1 In both surveys, women were first asked to name all of the family planning methods that they knew. Interviewers then probed to find out whether women recognized methods which they had not spontaneously mentioned. In the ZRHS, interviewers used only the name of the method when probing while, in the ZDHS, both the name of the method and a brief description were used. 40 Table 4,2 Percent of Currently Married Women Who Know at Least O~ Medern Contraceptive Method end Who Know a Source for e Modern Contraceptive Method by Selected Background Characteristics, ZinJ~abue DHS, 1988 Know Number Background Modern Know of Characteristic Metho<l Source Women Age 15-19 96,7 89,4 180 20-24 98,4 97,5 513 25-29 98,6 97,1 559 30-34 99,0 97,8 503 35-39 97,8 97,0 403 40-44 94,5 92,1 253 45-49 97,0 93,5 232 Urban-Rural Residence Urban 98,8 97,9 779 Rural 97,4 95,1 1 864 Place of Residence Manicatand 97,7 94,5 352 Mashonaland Central 95,4 94,5 217 Mashonaland East(l) 98,2 96,8 341 Hashonaland West 98,8 95,8 336 Matabetetand Rorth(2) 96,9 96,1 128 Matabeleland South 98,7 96,8 156 Midlands 97,2 95,5 398 Masvingo 96,8 94,9 312 Harare/Chitungwiza 99,0 97,5 204 Bulawayo 99,5 99,5 199 Level of Education NO Education 94,1 90,2 489 Primary 98,4 96,9 1 601 Secondary or Higher 99,5 98,2 553 Total 97,8 96,0 2 643 (1) Excludes Harare/Chitungwiza (2) Excludes Bulawayo the gap between the proportion knowing the method and knowing a provider for the method exceeds five percentage points only in the case of the condom, IUD and injection (Table 4.1). In view of the virtual universality of contraceptive knowledge among Zimbabwean women, it is not surprising that there is little variation across subgroups. In all subgroups shown in Table 4.2, over 90 percent of currently married women know a modern method, and almost as high a proportion can name a source for the method. 41 Perceived Providers Table 4.3 shows the providers to which women knowing a specific contraceptive method say that they would go to obtain the method if they wanted to use it. It is important to note that these data are collected from both users and nonusers; information on the service providers from which users actually obtain their method is presented later in the chapter. The majority of women name government-sponsored clinical facilities run by the Zimbabwe National Family Planning Council (ZNFPC), the Ministry of Health (MOH) and local governments as providers they would use for both supply and clinic methods. The importance of the ZNFPC outreach programme is evident in the fact that its community-based distribution (CBD) workers are mentioned by more than one in four women as a source for pills and by nearly one in five women as a source for condoms. There is little perception of the private sector as a provider for most methods; only 2 percent of women knowing about the pill say they would obtain it from a private doctor or pharmacy, and fewer than one in seven mention private doctors or pharmacies as a source for any method except foam/jelly/foaming tablets. Tabte 4.3 Percent Distribution of Women Who Know a Contraceptive Method by Source Where They Woutd Obtain Method if They Wanted to Use it, According to Specific Method, Zimbabwe OHS, 1988 Foam/ Je t ty / Femate Mate Periodic Perceived injec- Die- Foaming Ster i t - S ter i t - Absti- Source Pi t t iUD tion phragm Tabtets Condom isation isation nence CBD(1) 26,7 2,2 1,2 4,6 4,2 19,5 0,I 0,1 6,6 ZNFPC Ctinic 12,0 13,7 14,4 14,5 15,5 12,3 5,6 6,5 17,4 MOH Hospitat/Ctinic 19,2 40,7 39,3 31,5 24,2 19.0 65,8 59,4 9,6 Munlcipat/Loca[ Ctinic 15,2 9,4 10,4 5,1 9,9 13,3 2,5 1,6 5,6 Rural Council Ctinic 16,7 5,4 9,5 6,8 5,7 12,1 2,2 1,6 6,8 Coranerce/tndustry 0,3 0,1 0,5 0,3 0o0 0,4 0,0 0,0 0,1 Mission/Church 2,0 4,9 5,0 4,1 2,7 1,7 7,7 4,4 1,4 Schoo[ 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0 2,8 Private Doctor/Pharmacy 1,8 9,3 8,0 14,1 27,6 5,3 8,3 13,8 6,9 Friends/Relatives 0,1 0,0 0,0 0,0 0,4 0,2 0,0 0,1 16,5 Traditionat Heater 0,0 0,0 0,0 0,0 0,0 0,I 0,3 0,3 0,I Other 1,5 1,2 1,5 1,5 0,9 2,1 0,6 0,7 10,3 Nowhere 0,0 0,1 0,9 0,0 0,0 0,1 0, I 0,0 5,4 Don't Know 4,4 12,7 9,1 17,2 8,8 13,5 6,5 11,2 9,3 Missing 0,1 0,2 0,0 0,3 0,2 0,4 0,1 0,1 1,3 Totat 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 Number of Women 3 931 2 169 2 612 588 3 566 222 2 086 688 1 182 CSD = ZNFPC community-based d ist r ibut ion worker (1) Inctodes a few women who reported that they woutd obtain worker other than the ZNFPC CSD the method from a community-based 42 4.2 OTI~.R OBSTACLES TO FAMILY PLANNING USE Pcrcoivcd Problems in Using Methods While lack of information about a specific contraceptive method or about a service provider offering the method are obvious barriers to use of the method, there are many other factors, including concerns about side effects or the effectiveness of the method, which can stand in the way of a woman adopting a particular method. To obtain information on other obstacles to use, women who have heard of a method were asked about the main problem (if any) with using the method. Among those women who have heard of a method, two-fifths say that there is no problem with withdrawal, and one-third feel that there are no problems in using the pill, injection, condom, foam/jelly/foaming tablets and periodic abstinence (Table 4.4). Roughly a quarter think there are no problems with the diaphragm and male and female sterilisation. Health concerns were cited as the main problem for the pill (40 percent), the IUD (25 percent) and injection (19 percent). Health concerns also were mentioned as a problem for female sterilisation (15 percent), but the most frequently cited problem for this method, as well as for male sterilisation, was its irreversibility. Almost a third of the women were concerned with the perma- nent nature of sterilisation. The possibility that using injection might result in a woman's being unable to have children later was also perceived as a problem by some women (17 percent). Ineffectiveness was the most commonly cited problem with periodic abstinence (30 percent) and withdrawal (19 percent). Husband disapproval was rarely perceived as problem, except for withdrawal (14 percent) and, to a lesser degree, the condom (7 percent), possibly due to the need for the husband's active involvement in the use of these methods. Periodic abstinence, withdrawal, Table 4.4 Percent Distribution of women Who Know a Contraceptive Method by Main Problem Perceived in Using the Method, According to Specific Method, Zimbabwe DHS, 1988 Foam/ Peri- Jelly/ Female Male odic Znjec- Dia- Foaming Con- Sterit- Steril- Absti- With- Main Problem Pitt IUD tion phragm Tablets dem i sa t ion i sa t ion nence drawat No Problem 30,6 19,6 30,1 26,2 31,3 35,2 25,0 25,1 30,7 42,5 Health Concerns 40,5 25,0 19,3 7,3 10,8 2,8 15,1 8,3 0,1 0,7 Method Permanent 3,5 1,1 16,7 0,2 1,4 0,5 31,3 29,4 0,4 0,5 Inconvenient to Use 3,0 8,8 2,9 8,7 13,8 10,2 1,7 2,3 19,1 10,4 Not Effective 2,5 6,3 1,0 6,0 9,7 9,6 0,4 1,0 29,9 19,3 Access/Availability 0,1 0,3 0,5 0,7 0,5 0,2 0,0 0,1 0,0 0,0 Costs Too Much 0,0 0,1 0,4 0,3 0,7 0,0 0,1 0,1 0,0 0,0 Husband Disapproves 0,6 0,6 0,7 0,7 2,3 7,2 1,3 1,7 2,5 14,2 Other 0,2 0,0 0,2 0,3 0,2 0,2 0,7 1,3 0,3 0,2 Don't Know 18,9 37,9 28,0 49,3 29,0 33,4 24,3 30,5 16 ,2 11,5 Missing 0,2 0,2 0,0 0,3 0,4 0,7 0,2 0,0 0,7 0,8 Total 100,0 I00,0 100,0 100,0 100,0 100,0 100,0 I00,0 100,0 100,0 Number of Women 3 931 2 169 2 612 588 3566 3 222 2 086 688 1 182 2 665 43 foam/jelly/foaming tablets and condom were the methods mentioned most frequently as inconvenient to use. Cost of services and access/availability were not considered problems by many respondents; less than 1 percent report these problems for any method. For all methods, a substantial proportion of women were not able to name a problem with the method. Those falling into the "don't know" category may not be familiar enough with the methods to be able to specify problems, or they may be embarrassed to discuss problems with using some methods. Therefore, when a large proportion of women report that they do not know about any problem in using a method, this should not be interpreted as evidence that the method is "without problems" for women. Lack of adequate information about a method, including both its advantages and disadvantages, may in itself be the greatest barrier to use. Husband's Attitude Husband's disapproval of family planning can be a major obstacle to use for women. The ZDHS found that, among women knowing about family planning, over 70 percent believed their husband approved of family planning, 15 percent felt their husband disapproved and 11 percent were unsure about their husband's attitude (Table 4.5). Older women, women living in rural areas and women who never attended school or had only a primary education were more likely than other women to report that their husband disapproved of family planning or to say that they were unsure of their husband's attitudes. The differential between women with secondary education and women in the other two education groups is particularly large. Around 90 percent of women with a secondary education felt their husband approved of family planning compared with 70 percent of women with a primary education and only 60 percent of women with no education. Table 4.5 Percent of Currently Married Women Who Know a Contraceptive Method by Husband,s Approval of Family Planning, According to Selected Background Characteristics, Zimbabae DHS, 1988 Humber Background Don't TotaL of Characteristic Disapproves Approves Know Missing Percent Women Age 15-19 10,3 70,9 18,3 0,6 100,0 175 20-24 11,2 79,1 9,3 0,4 100,0 508 25"29 15,5 75,7 8,6 0,2 100,0 556 30-34 15,6 77,8 6,6 0,0 100,0 499 35-39 18,1 70,0 11,6 0,3 100,0 397 40"44 15,4 69,5 15,0 0,0 100,0 246 45-49 19,7 57,9 22,4 0,0 100,0 228 Urban-Rural Residence Urban 10,1 83,4 6,3 0,3 100,0 775 Rural 17,2 69,2 13,4 0,2 100,0 1 834 Level Of Education No Education 18,6 59,5 21,6 0,2 100,0 467 Primary 17,0 7Z,5 10,4 0,1 100,0 1 591 Secondary or Higher 6,5 88,0 5,1 0,4 100,0 551 Total 15,1 73,4 11,3 0,2 100,0 2 609 44 Women who said that their husband disapproved of family planning were asked their opinion as to the reason for his attitude. Nearly half pointed to the husband's desire for more children as the reason for his disapproval of family planning. Other reasons mentioned by the women included the husband's fears that the woman would be promiscuous (14 percent), health concerns (10 percent) and religious prohibitions against use of family planning (4 percent) (from survey data not shown in a table in this report). 4.3 OTHF~R FACTORS FACILITATING USE Couple Communication about Family Planning While discussion of family planning by a couple is not required as a prelude to contraceptive use, it is an indicator of the level of interest in family planning on the part of the couple. Table 4.6 shows the number of times currently married women knowing a family planning method reported that they had talked about family planning with their husband in the year before the interview. In view of the length of the recall period, the data are subject to reporting error, particularly with respect to the frequency of the discussions; however, they provide some insight into the prevalence of interspousal communication on the topic of family planning. Table 4.6 Percent Distribution of Currently Married Women Who Know a Contraceptive Method by Number of rimes Discussed Family Planning With Husband During the Year Before the Survey, According to Selected Background Characteristics, Zimbabwe DHS, 1988 Number of Times Discussed Family Planning Number Background More Total of Character ist ic Never Once Twice Often Missing Percent Women Age 15-19 43,4 18,9 7,4 30,3 0,0 100,0 175 20-24 28,3 15,4 8,9 47,2 0,2 100,0 508 25-29 25,2 16,5 7,7 50,5 0,0 100,0 556 30-34 22,8 13,8 8,2 55,1 0,0 100,0 499 35-39 32,2 12,1 7,6 48,1 0,0 100,0 397 40-44 40,2 8,5 6,9 44,3 0,0 100,0 246 45-49 46,1 9,2 4,8 39,9 0,0 100,0 228 Urban-Rural Residence urban 21,0 12,9 8,1 57,8 0,1 100,0 775 Rural 35,1 14,3 7,5 43,2 0,0 100,0 1 834 Level of Education No Educetion 51,4 10,3 7,9 30,2 0,2 100,0 467 Primary 29,4 14,8 6,5 49,3 0,0 100,0 1 591 Secondary or Nigher 18,0 14,2 10,7 . 57,2 0,0 100,0 551 Total 30,9 13,9 7,7 47,5 0,0 100,0 2 609 45 Overall, almost half of the women said that they had talked with their husband about family planning more than twice in the preceding year, 20 percent had had one or two conversations and about 30 percent had never discussed family planning with their husband. Couple communication about family planning was more prevalent among women age 20-34, urban women and women with secondary education than other women. Women who had never attended school were the least likely to discuss family planning with their husband; less than half had ever talked about family planning with her husband, and only one in three had had more than two conversations. Exposure to Mass Media In Zimbabwe, family planning information is regularly disseminated through the mass media. Information on the coverage of radio, television and print media is, therefore, important for formulating strategies for using these media for family planning education. Table 4.7 summarises information on the exposure of ZDHS respondents to mass media in the week before the survey. Overall, only about one in two women was regularly exposed to any of the media. Coverage was about equal for radio and print media (38 percent and 40 percent, respectively), while television reached far fewer women (16 percent). Both residence and educational level are related to the likelihood that a woman will have been exposed to any of the media. Over 80 percent of urban women were exposed to either radio, television or a newspaper compared with only 40 percent of rural women. The proportion exposed to any media increases directly with educational level, from 19 percent among women with no formal education to over 80 percent among women with secondary education. Looking at type of Tabte 4.7 Percent of Art Women RegutarLy Exposed to Mass Media by Type of Media, According to Setected Background Characteristics, Zimbabwe gHs, 1988 Exposed Number Background Print Tete- to Any of Characteristic Media(l) vis ion(2) Redio(3) Media women Urban-Rural Residence Urban 67,7 39,8 69,5 85,6 1 407 Rurat 26,4 3,8 22,4 39,2 2 794 Level of Education No Education 1,1 3,2 18,0 19,4 566 Primary 31,0 8,6 31,5 47,5 2 349 Secondary or Higher 74,3 34,8 59,3 83,4 1 286 Tota[ 40,2 15,9 38,2 54,7 4 201 (1) Includes those reading a newspaper or magasine at [east once a week (2) |nc[udes those watching televis ion every week (3) |nc[udes those l istening to radio every day 46 media, it is clear that television reaches a largely urban audience. Even among urban women, however, only 40 percent regularly watches television. Print media and radio reached two-thirds of urban women and one-quarter of rural women. Looking at the differentials for education groups, radio was the media providing the greatest coverage of women with no formal education; however, only 18 percent of women in this group reported regularly listening to radio broadcasts. F_,xp~ure to Family Planning Messages Data on exposure to family planning information in the month before the interview are shown in Table 4.8. Only 20 percent of women reported that they had read or heard anything about family planning during the month before the survey. Among those exposed to family planning information, radio and interpersonal communication with a health worker are the primary sources of the information. Urban women are more likely to report recent exposure to family planning information than rural women. The likelihood a woman will have heard or read about family planning recently is related to her educational attainment; women with secondary education are three times as likely as women with no formal education to have been exposed to family planning information in the month before the survey. Among those recently exposed to family planning information, the radio and contact with a health worker were the most frequently cited sources among urban women and women with secondary education, while contact with a health worker was the major source of family planning information for other women. Finally, despite the small proportion of women who have heard a family planning broadcast, 95 percent of women believe that it is acceptable to broadcast messages about family planning on radio or television (from survey data not shown in table in this report). Table 4.8 Percent of All Women Who Heard or Read Any Information about Family Planning During the Month Before the Survey by the Source of Information, According to Selected Background Characteristics, zimbabwe DHSo 1988 Never Heard Source of Family Planning Information or Read Humber Background Any In- Health News- of Characteristic formation Radio Worker paper Poster Other Wo¢nen Urban-Rural Residence Urban 69,2 17,] 10,4 4,5 ] ,4 5,9 1 407 Rural 84,5 4,] 9,4 1,8 1,8 1,8 2 794 Level of Education NO Education 90,8 2,] 6,6 0,2 0,7 1,2 566 Primary 81,5 7,6 10,4 1,6 1,] 1,5 2 369 Secondary or Higher 70,5 1],8 10,2 5,8 6,9 4,8 1 286 Total 79,4 8,7 9,8 2,7 2,3 2,5 4 201 Nots: Respondents may have cited more than one source of information. 47 4.4 EVER USE OF FAMILY PLANNING Experience with using family planning methods is widespread in Zimbabwe, with four out of every five currently married women having used at least one family planning method (Table 4.9). Ever-users are more likely to have adopted modern than traditional methods; 63 percent of married women have used a modern method, while 48 percent have relied on traditional methods. Considering ever use of specific methods, the pill is clearly the most frequently used family planning method; the proportion ever using the pill (57 percent) is more than three times that ever using the condom (17 percent) or injection (14 percent), the other commonly used modern methods. Experience with other supply or clinical methods is limited; 3 percent or less of married women report that they have used the IUD, vaginal methods, female sterilisation or male sterilisation. More than 40 percent of currently married women have relied on withdrawal, the most widely used traditional method. The likelihood that a woman has used a family planning method varies with the woman's age. Overall, the level of ever use among currently married women increases from 48 percent in Tabte 4.9 Percent of AiL Women and Currentty Married Women Who Have Ever Used a Contraceptive Method by Specific Method, According to Age, Zimbabwe DHS, 1988 Age Any Any Modern Injec- Vagi- Con- Method Method Pitt IUO tion nats(1) dom Any Perio- Sterit isation Tradi- dic Number tionat Absti- With- of Femate Mate Method nence drawat Other Women Art Women 15-19. 14,2 11,5 9,9 0,1 0,0 0,1 4,6 0,0 0,0 6,9 2,7 3,9 1,3 1 021 20-24 61,8 53,3 48,3 1,5 1,7 1,9 17,6 0,0 0,0 29,3 6,7 22,0 5,5 840 25-29 80~7 68,9 65,1 3,5 9,1 1,3 20,2 0,4 0,3 44,5 5,9 38,1 7,1 679 30-34 84,9 71,5 64,9 3,9 26,7 1,9 17,1 0,8 0,0 49,6 9,2 41,6 9,3 589 35-39 82,8 63,6 57,8 3,2 22,2 2,2 13,4 4,3 0,6 56,7 7,3 48,1 13,8 464 40-44 75,8 52,8 41,8 3,8 23,9 2,8 7,2 7,9 0,3 53,5 7,9 48,1 11,9 318 45-49 ~,6 40,3 31,0 5,2 20,3 2,8 6,2 6,2 0,0 53,1 7,6 44,1 14,5 290 Totat 60,4 48,4 43,4 2,5 11,2 1,5 12,8 1,7 0,1 35,6 6,2 29,4 7,3 4 201 Currentty Married Women 15-19 48,3 42,2 38,3 0,6 0,0 0,0 16,1 0,0 0,0 22,2 5,6 17,8 3,3 180 20-24 77,2 66,9 61,6 2,1 1,8 2,1 23,0 0,0 0,0 36,8 6,0 30,4 5,8 513 25-29 84,8 71,2 67,6 3,8 8,8 1,4 21,1 0,5 0,4 48,5 6,6 42,0 7,3 559 30-34 85,7 71,0 64,8 4,2 25,6 2,0 18,3 0,8 0,0 52,5 9,3 44,5 9,7 503 35-39 84,6 64,0 57,6 3,2 21,1 2,5 14,1 4,0 0,7 58,1 6,5 50,1 13,4 403 40-44 77,5 52,2 42,3 4,0 23,7 2,8 7,5 9,1 0,4 57,3 7,9 51,4 12,6 253 45-49 70,7 43,5 34,9 5,6 22,4 2,6 7,3 6,9 0,0 54,7 8,2 45,7 15,5 232 Totat 79,0 63,0 57,1 3,4 14,5 2,0 17,0 2,3 0,2 48,1 7,2 41,1 9,4 2 643 (1) Includes diaphragm and foam/jetty/foaming tabtets 48 the 15-19 group to 85 percent in the 25-39 groups, before decreasing among older women. Considering only modern methods, the level of ever-use rises from 42 percent among women 15- 19 to a peak of 71 percent among women 25-34, before declining to 44 percent in the oldest age group. Use of traditional methods shows a somewhat different pattern with age; the percent ever using a traditional method increases from 22 percent in the youngest age group to 58 percent among women 35-39, with only a slight decrease observed in the rate for the oldest cohorts. 4.5 TIMING OF FIRST USE Table 4.10 provides information on the number of living children women had at the time they began contracepting. The results indicate that there is a long tradition of initiating contraceptive use in the early stages of childbearing, presumably for spacing purposes. Overall, half of ever-married women--65 percent of all ever users--report that they began using some form of contraception before they had two children. Looking at the age patterns, it is clear that even ever-users in the oldest age cohorts began using family planning early on in the family building process, the majority after only one or two children. There is evidence of a trend toward increasingly early adoption of family planning; only one in three women in their forties began using family planning when they had fewer than two children compared with more than half of women under 25. To some extent, this trend may simply reflect the fact that modern contraceptive services have been more available to young women, than was the case for older women who had their first births in the 1960s and 1970s when the family planning programme was just beginning. The current availability of modern methods makes it likely that younger women also are initiating family planning with a more effective method (the pill) than their predecessors, who most likely relied on traditional methods such as withdrawal. Table 4.10 Percent Distribution of at Time of First Use of Zimba~e ONS, 1988 Ever-married women by Number of Living Children Contraception, According to Current Age, Number of Living Children Nunloer Current Never 4 or Total of Age Used None 1 2 3 More Hissing Percent Women 15-19 53,0 5,4 39,1 2,5 0,0 0,0 0,0 100,0 202 20-24 22,6 5,7 58,2 10,0 3,0 0,3 0,2 100,0 601 25-29 16,9 4,3 51,0 17,7 6,8 3,3 0,0 100,0 633 30-34 14,5 3,5 40,6 13,1 0,2 12,0 0,2 100,0 574 35"39 16,8 3,3 42,5 12,5 9,2 15,1 0,7 100,0 457 40-44 24,4 3,8 32,7 10,5 8,3 20,3 0,0 100,0 315 45-49 30,8 1,7 37,8 9,0 6,6 13,3 0,0 100,0 286 Total 22,0 4,0 46,8 12,1 6,4 8,6 0,2 100,0 3 068 49 60 Figure 4.1 Percent Who Had Fewer Than Two Children When They Began Using Contraception Percent of Ever-married Women 20-49 50 40 30 20 10 0 Zimbabwe Morocco tndonesia Ecuador The pattern of initiation of contraceptive use in Zimbabwe is quite different from that common in Asian, Near Eastern and Latin American countries. In many of these countries, the movement toward the adoption of family planning--and the transition to lower fertility--began with older, high-parity women seeking to limit births. In Zimbabwe, the desire to space births appears to have been the primary motivation for young, low-parity women to adopt modern contraceptive methods. The contrast in the "spacing" and "limiting" patterns is illustrated in Figure 4.1, which presents the proportion of women 20-49 who initiated contraceptive use when they had fewer than two living children. Only in the last 10-15 years have a substantial proportion of women in Indo- nesia, Morocco and Ecuador adopted family planning at an early stage of childbearing, a pattern that was common in Zimbabwe 20-30 years ago (Azelmat et al., 1989; CBS and IRD, 1989; and CEPAR and IRD, 1988). 4.6 KNOWf.EDGE OF FERTILE PERIOD A basic understanding of the reproductive cycle, especially an awareness of the fertile period, is important for the successful practice of family planning and particularly of periodic abstinence. Periodic abstinence has been used at some time by 6 percent of all women in Zimbabwe. Table 4.11 presents the distribution of all women and those women who have ever used periodic abstinence by the time during the ovulatory cycle that they think a woman is most likely to get pregnant. To obtain these data, respondents were first asked about when in the monthly cycle a woman has the greatest chance of becoming pregnant. If they did not understand the initial question, an additional probe asked them to identify the days when a women has to be careful to avoid becoming pregnant. It should be noted that the response categories developed for this question are one attempt at dividing the ovulatory cycle into distinct periods. It is possible 50 Table 4.11 Percent Distr ibut ion of Al l Women and Women Who Have Ever Used Periodic Abstinence by Knowiodge of the Fert i le Period During the Ovulatory Cycle, Zlmbsbue OHS, 1988 Periodic Al l Abstinence Fert i le Period Women Users During Her Period 1,5 1,5 After Period Ended 39,9 55,2 Middle of the Cycle 7,3 10,4 Before Period Begins 8,5 14,7 At Any Time 7,9 4,6 Other 1,2 1,5 Don=t Know 33,6 12,0 Missing 0,2 O,O Total 100,0 100,0 Number of Women 4 201 259 that some women who gave an answer of, say "one week after her period" were coded in the category "just after her period has ended," instead of in the category "in the middle of her cycle". Thus, women may actually have a more accurate understanding of the menstrual cycle than is reflected in Table 4.11. The results indicate that knowledge of the reproductive cycle is very limited. One-third of all women say that they do not know when the fertile period occurs, while 40 percent think it is just after a menstrual period has ended. Only 7 percent correctly identify the fertile period as occurring in the middle of the cycle. Even among women who have used periodic abstinence, 12 percent could not specify when the fertile period occurs; 56 percent said it is just after the period, and only 10 percent correctly identified it as occurring in the middle of the cycle. 4.7 CURRENT USE OF FAMILY PLANNING Levels and Differentials As shown in Table 4.12, 43 percent of currently married women are using contraception in Zimbabwe--36 percent modern methods and 7 percent traditional methods. Figure 4.2 shows that Zimbabwe has the highest level of contraceptive use reported among countries in sub-Saharan Africa for which recent information is available. Considering the method mix, the pill (31 percent) is the most commonly used method. Current use of other modern methods is very limited; 2 percent or less are using female sterilisation, the IUD, injection or the condom. The most prevalent traditional method, withdrawal, is currently used by 5 percent of currently married women. 51 t~ Table 4.12 Percent Distril~Jtion of AI[ Wo~en and Currently Married women by Contraceptive Method Currently Used, According to Age. ZiK~oabwe DHS, 1988 Age Any Any Hede~n Method Method P i l l Any Perio- SteriLisation Tradi- dic Number Injec- Vagi- Con- tional Absti o With- Not of IUD tion nals(1) dom Female Male Methed nence drawaL Other Using Women ALL Wocen 15-19 8,4 7,1 6,9 0,1 0,0 0,0 0,2 0,0 0,0 1,3 0,7 0,2 0,4 91,6 1 021 20-24 36.1 32.7 31.1 0.2 0.I 0,0 1,3 0,0 13,0 3,3 0,6 1,9 0,8 63,9 8/,0 25-29 47,1 41,5 38,0 1,5 0,I 0,I 1,0 0,4 0,3 5,6 0,1 4,1 1,3 52,9 679 30-34 48,4 41,6 37,9 1,0 0,3 0,0 1,5 0,8 0,0 6,8 0,7 4,6 1,5 51,6 589 35-39 41,2 31,2 23,1 1,3 0,4 0,0 1,5 4,3 0,6 9.9 0,4 7.1 2,4 58,8 464 40-44 34,6 25,5 15,7 0,6 0,9 0,0 0,0 7,9 0,3 9,1 0,0 6,9 2,2 65,4 318 45-49 19,7 14,5 6,9 0,7 0,0 0,0 0,7 6,2 0,0 5,2 0,3 2,8 2,1 80.3 290 Total 32,2 27,2 23,5 0,7 0,2 0,0 0,9 1,7 0,1 5,0 0,5 3,2 1.3 67.8 4 201 Currently Married Women Total 43,1 36,1 31,0 I~I 0,3 0,0 1,2 2,3 0,2 7,0 0,3 5,1 1,5 56,9 2 643 (I) Includes diaphragm arid foam/jelly/foaming tablets 15-19 30,0 28,3 27,8 0,6 0.0 0,0 0,0 0,0 0,0 1,7 0,0 1,1 0,6 70,0 180 20-24 45,8 41,5 39,8 0,4 0,0 0,0 1,4 0,0 0,0 4,3 0,4 3,1 0,8 54,2 513 25-29 50,3 43,8 39,7 1,6 0,2 0,2 1,3 0,5 0.4 6,4 0,2 5,0 1,3 49,7 559 30-34 50,5 42,9 39,2 1,2 0,2 0,0 1,6 0,8 0,0 7,6 0,6 5,4 1,6 49,5 503 35-39 41,7 30,8 22,3 1,3 0,5 0,0 1,7 4,0 0,7 10,9 0,2 8,2 2,5 58,3 403 40-44 37,2 26,1 14,6 0,8 1,2 0,0 0,0 9,1 0,4 11,1 0,0 8,7 2,4 62,8 253 45-49 22,8 17,2 8,6 0,9 0,0 0,0 0,9 6,9 0,0 5,6 0,4 3,4 1,7 77,2 232 Figure 4.2 Current Use By Type of Method Botswana Burundi Ghana Kenya Liberia ~ R Mall Ondo State, Nigeria Senegal Togo Uganda Zimbabwe + 34 ~6 . . - . . . . . - .+ . :q 34 43 0 10 20 30 40 50 Percent of Currently Married Women m Modern Method ~ Trad. Method I I DH$ surveys: Africa The level of current use varies with age, peaking at 50 percent among currently married women 25-34 (Table 4.12). However, even among younger and older cohorts, substantial proportions of women are using contraception--over 40 percent in the 20-24 and 35-44 cohorts and 20-30 percent in the 15-19 and 45-49 groups. Looking at the number of living children, there appears to be little interest in postponing the first birth; only 3 percent of married women with no children are using contraception (Table 4.13). Among married women with at least one living child, the proportion using exceeds 40 percent, regardless of the parity category, peaking at 50 percent among women with three children. The urban-rural differential is fairly large; 52 percent of currently married women in urban areas are using contraception compared to 40 percent of rural women (Table 4.13). Among urban women, the contraceptive prevalence rate is somewhat greater for those living in Harare/ ChJtungwiza than in Bulawayo. The rate is considerably lower in Matabeleland North, Matabele- land South and Manicaland than in other provinces. Increasing educational attainment is directly associated with use. For example, among women who have never attended school, only one in three are currently using family planning compared with half of the women with at least some secondary education. The overwhelming dominance of the pill makes it difficult to discuss differences in the method mix among subgroups. However, there is some tendency for use of methods other than the pill, particularly female sterilisation and traditional methods, to increase with age and with the number of living children. Among urban women, 9 percent are using a modern method other than the pill (primarily female sterilisation or the IUD) compared to 3 percent among rural women, while the prevalence of use of traditional methods is greater among rural (9 percent) than urban 53 4~ Table 4.13 Percent Distribution of Currently Married Women by Contraceptive Method Currently Used, According to Selected Background Characteristics, Ziml~abwe DHS, 1988 Any Perio- Any Steritisation Tradi- dic Number Background Any Modern lnjec- Vagi- Con- tionat Al~ti- With- Not of characteristic Method Method Pill ]LID tion nals(1) dm Female Mate Method nence drawal Other Using Women Rumber of Living children None 3,2 1,6 1,6 0,0 0,0 0,0 0,0 0,0 0,0 1,6 O,O 1,1 0,5 96,8 188 1 43,5 40,2 37,2 1,0 0,0 0,0 1,8 0,3 0,0 3,3 0,3 2,0 1,0 56,5 398 2 46,2 42,1 35,5 2,4 0,2 0,2 1,2 1,7 0,7 4,1 0,5 3,4 0,2 53,8 411 3 49,7 42,9 37,6 1,6 0,3 0,0 0,8 2,1 0,5 6,9 0,0 6,1 0,8 50,3 378 4 or More 45,9 36,0 30,0 0,6 0,4 0,0 1,3 3,6 0,I 9,9 0,4 7,0 2,4 54,1 1 268 urban-Rural Residence Urban 51,7 48,8 39,7 2,8 0,5 0,I 1,5 3,6 0,5 3,0 0,5 1,4 1,0 48,3 779 Rural 39,5 30,8 27,4 0,3 0,2 0,0 1,0 1,8 0,I 8,6 0,2 6,7 1,7 60,5 I 864 Place of Residence Manicaland 32,1 25,6 22,2 0,3 1,1 0,0 0,9 1,1 0,0 6,5 0,0 5,4 1,1 67,9 352 Mashonaland Central 47,5 40,1 36,4 1,4 0,0 0,0 1,8 0,5 0,0 7,4 0,0 6,9 0,5 52,5 217 Mashonaland East(2) 47,8 43,1 37,5 1,5 0,0 0,0 1,2 2,6 0,3 4,7 0,3 3,2 1,2 52,2 341 Mashonatand West 48,2 43,2 37,8 0,9 0,6 0,0 1,2 2,4 0,3 5,1 0,6 3,0 1,5 51,8 336 Matabeteland North(3) 27,3 18,0 17,2 0,0 0,0 0,0 0,0 0,8 0,0 9,4 0,0 7,0 2,3 72,7 128 Matabetetand South 28,2 21,2 17,3 0,6 O,O O,O 0,0 2,6 0,6 7,1 0,6 5,1 1,3 71,8 156 Midlands 44,7 35,2 29,6 1,0 0,3 0,0 1,0 3,3 0,0 9,5 0,5 7,8 1,3 55,3 398 Masvingo 47,8 35,3 31,1 0,0 0,0 0,0 2,2 1,9 0,0 12,5 0,0 8,3 4,2 52,2 312 Harare/Chitungwiza 51,5 48,0 41,2 0,5 0,0 0,0 1,0 3,9 1,5 3,4 0,0 3,4 O,O 48,5 204 gutawayo 43,7 41,2 30,2 5,0 0,0 0,5 1,5 4,0 0,0 2,5 1,0 0,0 1,5 56,3 199 Level of Education No Education 32,5 24,9 22,1 0,0 0,0 0,0 0,8 2,0 0,0 7,6 0,2 6,3 1,0 67,5 489 Primary 42,0 34,0 30,4 0,4 0,2 0,0 1,1 1,7 0,1 8,1 0,3 6,1 1,6 58,0 1 601 Secondary or Higher 55,5 52,3 40,7 3,8 0,5 0,2 1,8 4,3 0,9 3,3 0,4 1,3 1,6 44,5 553 Total 43,1 36,1 31,0 1,1 0,3 0,0 1,2 2,3 , 0,2 7,0 0,3 5,1 1,5 56,9 2 643 (1) Includes diaphragm and foam~jelly~foaming (2) Excludes Harare/Chitungwiza (3) Excludes Butavayo tabtets women (3 percent). Women who have attained the secondary level also are somewhat more likely to be using a modern method other than the pill and somewhat less likely to be using a traditional method than women having less formal education. Trends in Current Use A comparison of the findings of the ZDHS with the results of the 1984 Zimbabwe Repro- ductive Health Survey (ZRHS) highlights some important changes in both the level and the pattern of contraceptive use in Zimbabwe. First, the overall level of contraceptive use among currently married women increased during the four-year period between the two surveys by 5 percentage points, from 38 percent in 1984 to 43 percent (Table 4.14). Considering the change in relative terms, the prevalence rate increased during the period between the surveys by 12 percent. More importantly, today's users are much more likely to be relying on modern methods than those four years ago. During the period between the surveys, there was a one-third increase in the proportion of women relying on more effective methods; currently, 36 percent of married women are using modern methods, compared with 27 percent in 1984 (Figure 4.3). The increased Table 4.14 Percent of Currentty Married Women by Contraceptive Method Currently Used, Zimbabwe DHS, 1988 and RHS, 1984 Contraceptive 1988 1984 Absolute Method ZDHS ZRHS Difference Any Method 43,1 38,4 4,7 Any Modern Method 36,1 26,6 9,5 Pitt 31,0 22,6 8,4 IUD 1,1 0,7 0,4 Injection 0,3 0,8 -0,5 Vaginats(1) 0,0 0,1 -0,1 Condom 1,2 0,7 0,5 Female Steril isation 2,3 1,6 0,7 Mate Steril isation 0,2 0,1 0,1 Any Traditional Method 7,0 11,8 -4,8 Periodic Abstinence(2) 0,3 0,6 -0,3 githdrawal 5,1 6,5 -1,4 Abstinence NA 2,1 -- Other Methods(3) 1,5 2,6 -1,1 Number of Women 2 643 2 123 Source: Zimbabwe National Family Planning Council and Westinghouse Public Applied Systems, 1985 HA = Not available (1) Includes diaphragm and foam/jetty/foaming tablets (2) Reported as rhythm (calendar) in the ZRHS (3) Reported as folk methods in the ZRHS 55 Figure 4.3 Current Use of Contraception by Method, ZRHS 1984 and ZDHS 1988 Not Using 72% Not Using 57% Tr~H 7% ad. 6=/, Other Other Mod. 5% Mod. 4% ill 23% Pill 31% 1984 1988 Zimbabwe DHS 1988 use of modern methods was accompanied by a decline in the use of traditional methods, from 12 percent in 1984 to 7 percent in 1988. As a result of these changes, four in every five users now rely on modern contraceptives, compared with seven in ten users in 1984, suggesting that overall contraceptive practice may be somewhat more effective now than in the past. Almost all of the increase in the use of modern methods between the two surveys was due to increased use of the pill. The proportion of users relying on the pill increased by a third, from 23 percent in 1984 to 31 percent, while use of all other modern methods grew by only 20 percent (from 4 percent to 5 percent). With use of traditional methods declining, the pill has become even more dominant in the method mix among users. Currently, 72 percent of all users rely on the pill, while in 1984 only 60 percent used the pill. Table 4.15 shows the changes in the level of contraceptive use that occurred among various subgroups between the ZRHS and the ZDHS. The proportion of married women using contracep- tive methods increased in all age groups, except the 40-44 cohort where it remained almost constant. In absolute terms, the largest increases in use are observed for women in the 25-34 cohorts. The prevalence of use of all methods increased by roughly 8 percentage points in the 25-34 age groups, while the use rate for modern methods increased by 14 percentage points. Considering the number of living children, the absolute increase in contraceptive use was greatest for women with 1-2 children. Between the ZRHS and the ZDHS, significant increases in the use of contraceptive methods occurred for subgroups which had the lowest levels of use in 1984. Among rural women, the prevalence of use of all methods increased from 34 percent in 1984 to 40 percent, while the use of modern methods increased from 20 percent in 1984 to 31 percent. A similar increase 56 Table 4.15 Percent of Currently Married Women Currently Using Any Method And Any Modern Method, by Selected Background Characteristics, Zin~abae DHS, 1988 and RHS, 198/* 1988 ZDRS 1984 ZRHS Any Any Background Any Modern Any Modern Characteristic Method Method Method Method Age 15o19 30,0 28,3 24,9 16,2 20°24 45,8 41,5 43,6 34,4 25-29 50,3 43,8 42,3 28,2 30-34 50,5 42,9 42,8 29,1 35-39 41,7 30,8 37,1 22,1 40-44 37,2 26,1 37,6 26,8 45-49 22,8 17,2 21,2 13,9 Number of Living children None 3,2 1,6 7,1 4,8 I-2 44,9 41,2 38,9 28,6 3-5 49,3 42,5 46,9 32,0 6 or More 42,8 29,8 39,0 25,5 Urban-Rural Residence Urban 51,7 4B,B 46,6 59,4 Rural 39,5 30,8 34,0 19,9 Level of Education No Education 32,5 24,9 25,2 16,5 Some Primary 39,8 30,3 37,0 23,0 Completed Primary 46,6 42,5 48,6 35,6 Secondary or Higher 55,5 52,3 48,8 41,4 Total 43,1 36,1 38,4 26,6 Source: Zimbabwe National Family Planning Council and Westinghouse Public Applied Systems, 1985 occurred for women who never attended school; among these women, the use of all methods increased from 25 percent in 1984 to 32 percent, while the use of modern methods increased from 16 to 25 percent. Despite increased use among these groups, differentials in the level of contraceptive use between subgroups continue to be large. The differential in the contraceptive prevalence rate between urban and rural areas (12 percentage points) is virtually identical to the urban-rural differential in 1984, while the differential between women with no formal education and those with a secondary or higher education (23 percentage points) is almost the same as the differential observed between these groups in 1984. 4.8 SOURCE FOR C'ONTRACEP'ITVE ML~THODS Table 4.16 presents the distribution of current users of modern methods according to the source from which they most recently obtained their method. Almost all users rely on government- 57 Table 4.16 Percent Distribution of Current Users by Nost Recent Source for Nethod, According to Specific Method and Urban-Rural Residence, zimbabwe DHS, 1988 At[ Users Any Any Female Source for Supply CLinic Steril- Any Urban Rural Method Method Pill Condom Nethod IUO isation Method Users Users CBD(1) 25,3 25,7 21,0 0,0 0,0 0,0 24,5 4,2 36,1 ZNFPC Clinic 13,7 13,8 10,5 7,5 24,1 1,4 13,1 19,9 8,4 MOH Hospital/Clinic 14,8 14,8 10,5 57,5 13 ,8 74,6 18,8 22,4 16,1 Municipal/Local Clinic 19,1 19,2 18,4 7,5 13,8 4,2 18,0 35,3 5,8 Rural Council Clinic 17,7 18,1 13,2 0,0 0,0 0,0 16,1 5,7 23,4 Colrl~erce/lndustry 0,6 0,6 0,0 0,0 0,0 0,0 0,5 0,4 0,6 Nission/Church 1,6 1,7 0,0 3,8 3,4 4,2 1,8 0,4 2,8 Private Doctor/Pharmacy 2,3 1,4 15,8 17,0 31,0 11,3 3,7 7,8 0,7 Friends/Relatives 1,5 1,3 7,9 0,9 3,4 0,0 1,4 1,1 1,8 Traditional Healer 0,5 0,5 0,0 0,0 0,0 0,0 0,5 0,0 0,7 Other 2,8 2,9 0,0 3,8 10,3 1,4 1,4 2,3 3,3 aonlt Know 0,1 0,0 2,6 0,0 0,0 0,0 0,1 0,0 0,1 Miss ing 0,0 0,0 0,0 1,9 0,0 2,8 0,2 0,4 0,0 Total 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 100,0 Number of Current Users 1 037 989 38 106 29 71 1 143 4?3 670 CBD = ZNFPC community-based distribution worker (1) Includes a few wo~en who reported that they obtained their method from a community-based worker other than a ZNFPC CBD (R=lO) sponsored service providers for contraceptive methods. Around one in three users of supply methods (largely the pill) obtained her method from a clinic operated by the Zimbabwe National Family Planning Council (14 percent) or from one of the ZNFPC-sponsored community-based distribution (CBD) workers (25 percent). Most other supply method users relied on clinics operated by the Ministry of Health (MOH) or local government; only 2 percent obtained their supplies from a private doctor or pharmacy. Government-sponsored outlets are also the principal provider of clinical methods to the small number of users relying on these methods. Three of every four sterilisations were performed at MOH outlets, while ZNFPC clinics were the most frequently cited public sector provider for the IUD. Users of clinical methods are somewhat more likely than users of supply methods to turn to the private sector for services; 17 percent report obtaining their clinical methods from a private doctor, with the small number of IUD users being most likely to report obtaining their method from a private doctor. The importance of the CBD workers in the providing services to rural users is highlighted in Figure 4.4. Around one-third of rural users rely on the worker for their method (principally the pill). Rural council clinics are the other major providers of contraceptive services in rural Zimbabwe; one-fourth of rural users obtained their methods from these clinics, while 16 percent go to Ministry of Health hospitals or clinics and 14 percent rely on ZNFPC clinics or municipal/ 58 100 80 60 40 20 0 Figure 4.4 Source for Contraceptive Methods Among Current Users by Urban-Rural Residence Percent of Users Total Urban Rural m CBD/Worker ~ ZNFPC Clinic Priv. MD/Phar. ~ Other Other Gov't ClinicB I Ztmbabwe DHS 1988 local government clinics. Municipal/local government clinics are the primary providers of methods to urban users, followed by Ministry of Health and ZNFPC facilities. Most users (95 percent) are satisfied with their service providers (from survey data not shown in table in this report). Only 5 percent indicated that they were not happy with the service they had received. Among these dissatisfied users, common complaints included discourteous staff, long waits, inability to obtain the desired method and the high cost of services. 4.9 p l l J . USE The pill is the most popular modem method of contraception in Zimbabwe; more than 80 percent of women using a modern method rely on the pill. To obtain information on the brand of pills being used by women, current users were asked to show the packet of pills they were taking at the time of the interview. Table 4.17 shows that 92 percent of pill users were able to show the interviewer a pill packet. Looking at the brands used, pill users are fairly evenly divided between Table 4.17 Percent Distribution of Current Users of the P i l l by Brand Used, According to Breastfeeding Status, Zimbabwe DHS, 1988 Not ALL P i l l Breast- Breast- PiLL Brand feeding feeding Users Lo-Femenal 8,6 64,7 41,6 Ovrette 79,9 24,1 47,1 Other 1,2 4,8 3,3 Not Able to Show 9,8 6,0 7,6 Missing O,S 0,3 0,4 Total 100,0 100,0 100,0 Number of Pitt Users 408 581 989 59 Lo-Femenal and Ovrette, the two brands available through public sector outlets. In line with programme recommendations, the majority of pill users who are currently breastfeeding use Ovrette (a progestin-only pill which does not reduce milk production), while, among those not breastfeeding, the majority use Lo-Femenal (a low-dose pill). Most pill users pay for their supply; only one-third report receiving the pill free of charge. Among those paying for the pill, almost all pay less than one Zimbabwe dollar for a packet; 50 percent of pill users report paying 20 cents and 10 percent report paying 40 cents (from survey data not shown in table in this report). In order to study the quality of use of the pill, several questions were included in the ZDHS to determine whether women using the pill comply with instructions to take the pill daily and their actions if they forget to take the pill. To the extent that the questions rely on recall, the responses may tend to understate problems that exist in taking the pill, since users may not remember whether they have been consistent in taking the pill or what they did if they forgot. As Table 4.18 shows, about one-fifth of pill users indicated that they had interrupted use for at least one day during the month prior to the survey. Rural users (22 percent) were only slightly more likely than urban users (19 percent) to say that they had interrupted use. Interruption of use was somewhat more likely to be reported by users who obtained the pill from a CBD worker than by users who relied on other outlets for their supply; the differentials by source are, however, minor, ranging from a low of 15 percent for users obtaining the pill from Ministry of Health hospitals or clinics to 29 percent for the few users obtaining the pill from a private doctor or pharmacy. Table 4.18 Percent of Current Users of the P i l l Saying They Interrupted Use For At Least One Day During the Month Before the Survey by Source Where They Obtained the P i l l , According to Urban-Rural Residence, Zimbabwe DNS, 1988 Humber of Pi l l Source Urban Rural Total Users CBD(1) 15,0" 25,7 24,8 254 ZHFPC CLinic 16,3 26,0 19,9 136 MOH Hospital/Clinic 17,1 12,9 15,1 146 Municipal/Local CLinic 20,3 29,7 22,1 190 Rural Council Cl inic 14,8 23,0 21,8 179 Co~)erce/industry 0,0" 0,0" 0,0" 6 Mission/Church 0,0" 18,8" 17,6" 17 Pr ivate Doctor~Pharmacy 28,61 0,0 28,6 t 14 Friends/Relatives 50,0* 0,0" 7,7* 13 Tradit ional Healer 0,0" 0,0" 0,0" 5 Other 37,5* 14,3 20,7 29 Total 18,8 22,3 20,9 989 * Percent based on fewer than 25 cases (1) Includes a few women who reported that they obtained the i r method from a conlnunity-based worker other than the ZNFPC CSD 60 Pill users who admitted that they had interrupted use were asked about the reasons for stopping use (Table 4.19). Although most cited only one factor, users were able to give more than one reason for the interruption of use. Forgetting to take a pill or misplacing the packet were mentioned by 79 percent as a reason for the interruption in use, while 6 percent said that they ran out of pills. Only 7 percent said that they were bothered by side effects (including spotting and bleeding), and another 5 percent said that they did not take the pill because they were not sexually active at the time. Since forgetting to take the pill appears to be one of the main reasons for interrupting use, it is important to know what action pill users take when they forget to take a pill. When asked what they did the last time that they missed taking a pill, slightly more than one-third said they had never forgotten to take a pill (Table 4.20). Among the users who said they had forgotten at least once, the most common--and correct--action was to take two pills the next day; 30 percent of pill users fell into this category. However, a roughly similar proportion of pill users indicated that when they forgot the pill, they either did nothing (5 percent) or took only one pill the following day (24 percent). The results suggest that the majority of pill users in Zimbabwe are taking the pill consistently and correctly. The effectiveness of the pill may be reduced, however, for a significant minority of users who do not take appropriate action when they fail to take the pill for at least a day. Providers need to stress Table 4.19 Percent o f Current Users of the PiLl Who Interrupted Use For At Least One Day During the Month Before the Survey by Reason fo r Interrupting Use, Zimbabwe DHS, 1988 Reason for Interrupting Use Side Effects/ I l lness 5,8 spotting/BLeeding 1,0 Period Did Not Come 0,5 Ran Out of PiLls 6,3 Forgot/MispLaced PiLLs 78,7 Not Sexually Active 4,8 Other 2,4 Number of P i i [ Users 207 Note= Users may have given more than one re6son for interrupting use. Table 4.20 Percent Distrf~z~Jtion of Current Users of the PiLl by Action Taken i f PilL Forgotten, Zimbabwe DHS, 1988 Action Taken i f P i l l Forgotten Took One P i t t Next Day 24,1 Took Two PiLLs Next Day 30,7 Used Another Method 0,5 Old Nothing 5,0 Abstained 0,4 Other 1,9 Never Forgot 37,2 Missing 0,2 Total 100,0 Number of P i t t Users 989 what to do when the pill is forgotten, misplaced or unavailable--by far the most common reasons for interruption of use--and to remind clients that alternate methods are available if they are bothered by side effects or have intercourse only infrequently. The family planning programme may also want to broaden access to methods like the IUD and female sterilisation that may be more suitable for women who are seeking to limit rather than to space births. The number of women wanting to limit births appears to be increasing in Zimbabwe, according to the data on reproductive intentions presented in Chapter 5. 61 4.10 ATI l l t JDES ABOUT PREGNANCY AND REASONS FOR NONUSE Although the use of contraceptives and especially of modern methods, is widespread in Zimbabwe, there remains a substantial number of women who are not currently using although they are in immediate need of contraception to prevent an unplanned pregnancy. Overall, 52 percent of married women are sexually active, not currently pregnant and not contracepting. When women in this group were asked about their reaction to the possibility of becoming pregnant in the next few weeks, more than one-third said that a pregnancy would pose problems (Table 4.21). The proportion who felt that a pregnancy would pose problems increases with the number of children the woman already has, peaking at 46 percent among women with four or more living children. Even among women with no living children, however, one in four said that a pregnancy would pose problems. When asked for the reason a pregnancy would pose problems, women were most likely to mention already having other young children (29 percent), the belief a pregnancy would be unhealthy (21 percent) or being unable to afford another child (18 percent) (from survey data not shown in table in this report). For women who stated that a pregnancy in the next few weeks would pose problems, a further question was asked why they were not using contraception. Unlike the information presented earlier in this chapter on the main problems with methods, the responses here are personal, reflecting the reason that the woman herself has for not using any method of contraception, rather than the obstacles or barriers that she perceives might keep other women from using a specific method. The reasons for nonuse presented in Table 4.22 suggest that somewhat more than one-fifth of the women are not using because they consider themselves to be at limited risk of pregnancy, largely since they have sexual intercourse infrequently. Among the remaining women, the reasons for nonuse are diverse, but about six in ten women cite as reasons for nonuse variables which the family planning programme in Zimbabwe can address. A key issue is the availability of methods. Around one in five of these women points to Table 4.21 Percent Distr ibut ion of Non-pregnant Women Who Are Sexually Active and Not Using Any Contraceptive Method, by Att itude Toward BecOming Pregnant in the Next Few Weeks, According to Number of Living Children, Zimbabwe DHS, 1988 Would Would Not Number Number of Pose Hatter Don~t Total of Living Children Problerr~ Very Much Know Missing Percent Women None 26,6 63,5 8,0 1,1 100,0 274 1 30,2 63,5 5,9 0,5 100,0 222 2 36,4 59,9 3,7 0,0 100,0 187 3 34,2 60,1 5,1 0,6 100,0 158 4 or more 45,8 44,6 8,3 1,3 100,0 552 Total 37,0 55,1 7,0 0,9 100,0 1 393 62 Table 4.22 Percent Distribution of Non-pregnant Women Who Are Sexually Active and Not Using Any Contra- ceptive Method and tdho Say that I t Would Pose Problems i f They Became Pregnant by Ms|n Reason for Nonuse, According to Age, zimbabwe OHS, 1988 Age Reason for Nonuse 15-29 30-49 Total opposed to Family'Ptanning 4,9 4,9 4,9 Husband Disapproves 9,7 8,1 8,7 Others Disapprove 1,5 0,6 1,0 Religious Objections 5,8 ],6 4,5 Infrequent Sex 17,5 20,7 19,4 Postpartum/Breastfeeding 3,9 1,6 2,5 Menopausat/Subfecund 0,5 0,3 0,4 Health Concerns 2,9 3,2 3,1 Lack of Knowledge 9,7 3,9 6,2 Inconvenient to Use 0,5 20,7 12,6 Access/Availability 23,3 14,6 18,1 COSTS TOO Much 2,9 3,9 3,5 Fatalistic 1,0 1,6 1,4 Other 10,7 10,7 10,7 Don't Know 5,5 1,0 2,7 Missing 0,0 0,6 Oe4 Total 100,0 100,0 100,0 Number of Womene 206 309 515 lack of access (18 percent) or cost (4 percent) as the main reason for nonuse. Women under 30 are more likely than older women to mention access problems. A substantial proportion of older women (21 percent), but almost no women under 30, say they are not contracepting because they find methods inconvenient to use. Lack of knowledge about family planning is given by 6 percent as the reason for not using, with younger women mentioning it more often than older women. An additional 14 percent say that either their husband or others disapprove, or they themselves are opposed to family planning, and 4 percent mention religious prohibitions against contraception. Only 3 percent mention health concerns as a reason for nonuse, although health concerns were cited frequently as the main problem in using contraceptive methods, especially the pill (see Table 4.4). These findings raise issues which the family planning programme in Zimbabwe can address. Of key concern is the problem of improving access to contraceptive services, particularly in rural areas. Currently, services are not readily available for many rural women. According to the results of the Catchment Area Survey conducted by the ZNFPC, only 29 percent of the rural population are covered by the CBD programme (Zimbabwe National Family Planning Council, 1987). Moreover, many health facilities serving rural areas do not offer family planning services. The lack of ready access to services is compounded by the fact that some nonusers perceive the methods most readily available--primarily the pill and the condom--as inconvenient to use. Expanding the range of methods offered by providers would address the increasing need for methods appropriate for limiting rather than spacing births, a topic discussed further in the next chapter. 63 Table 4.23 Percent Distr ibut ion of Currently Married Women Who Are Not Currently Using Any Contraceptive Method by Intention to Use in the Future, According to Number of Living Children, Zimbabwe DHS, 1988 Number of Living Children(I) Intention to 6 or Use in the Future None I 2 3 4 5 More Total Inter.~ to Use in Next 12 Months 13,4 36,4

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