Family Planning and Reproductive Health Survey 2003

Transcription

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2 Family Planning and Reproductive Health Survey 2003 End-of-Project Survey of Selected Pilot and Control Districts in Malawi Population and Family Planning Project Ministry of Health and Population Lilongwe, Malawi ORC Macro Calverton, Maryland, USA September 2003

3 This report presents the findings of the 2003 Family Planning and Reproductive Health Survey (FPRHS03), an endof project study of selected districts in Malawi where a community-based family planning delivery system was piloted and selected control districts. The FPRHS03 was implemented by the Population and Family Planning Project (PopFP) of the Ministry of Health and Population. Funding for the survey was provided by PopFP under a loan agreement between the Ministry of Health and Population and the World Bank. Technical assistance was provided by ORC Macro. Additional information about the 2003 Family Planning and Reproductive Health Survey and the PopFP project may be obtained from the Population and Family Planning Project, Ministry of Health and Population, P.O. Box 30377, Lilongwe, Malawi (tel: ; fax: ; popfp@malawi.net). Further information about design elements of the survey, which was partially modeled on the 1999 Malawi Demographic and Health Survey, can be obtained from ORC Macro, DHS, Beltsville Drive, Suite 300, Calverton, MD (tel: ; fax: ; reports@orcmacro.com; internet: Recommended citation: Population and Family Planning Project (PopFP), Ministry of Health and Population [Malawi] and ORC Macro Family Planning and Reproduction Health Survey 2003: End-of-Project Survey of Selected Pilot and Control Districts in Malawi. Lilongwe, Malawi and Calverton, Maryland (USA): PopFP and ORC Macro.

4 CONTENTS TABLES AND FIGURES...v EXECUTIVE SUMMARY...vii MAP OF MALAWI...x CHAPTER 1 INTRODUCTION Geography, Population and Economy The Population and Family Planning Project The Family Planning and Reproductive Health Surveys, 1999 and Organization of the Family Planning and Reproductive Health Survey Sample Design Questionnaires Training and Fieldwork... 4 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Household Population Age-Sex Composition Household Composition Housing Characteristics Characteristics of Respondents CHAPTER 3 FERTILITY REGULATION Knowledge of Contraceptive Methods Ever Use of Contraception Current Use of Contraceptive Methods Number of Children at First Use of Contraception Source of Family Planning Methods Contact of Nonusers of Family Planning with Family Planning Providers Attitudes of Women Toward Family Planning CHAPTER 4 FERTILITY PREFERENCES Fertility Preferences of Currently Married Women by Number of Living Children CHAPTER 5 AIDS KNOWLEDGE AND PREVENTION Knowledge of HIV/AIDS Knowledge of Ways to Avoid HIV/AIDS Knowledge of Programmatically Important Ways to Avoid AIDS Knowledge of Issues Related to Transmission of the AIDS Virus Knowledge of a Source for Condoms Use of Condoms during Last Sexual Intercourse APPENDIX A: FAMILY PLANNING AND REPRODUCTIVE HEALTH SURVEY STAFF, APPENDIX B: QUESTIONNAIRES...41 iii

5 TABLES AND FIGURES Table 1.1 Demographic indicators... 2 Table 1.2 Results of the household and individual interviews... 5 Table 2.1 Household population by age and sex...7 Table 2.2 Household composition... 9 Table 2.3 Housing characteristics Table 2.4 Respondent background characteristics Table 3.1 Knowledge of contraceptive methods Table 3.2 Knowledge of contraceptive methods among currently married women by background characteristics Table 3.3 Ever use of contraception among women who know of at least one method Table 3.4 Current use of contraception Table 3.5 Number of children at first use of contraception for ever-married women Table 3.6 Source of supply among current users Table 3.7 Contact of nonusers with family planning providers Table 3.8 Approval of family planning Table 4.1 Fertility preferences of currently married women by number of living children Table 5.1 General knowledge of HIV/AIDS Table 5.2 Knowledge of ways to avoid HIV/AIDS Table 5.3 Knowledge of specific ways to avoid getting the AIDS virus Table 5.4 Percentage of women who know of HIV/AIDS by responses to questions on various AIDS-related issues by residence Table 5.5 Knowledge of condoms and sources Table 5.6 Use of condoms Figure 2.1 Population pyramid, pilot districts... 8 Figure 2.2 Population pyramid, control districts... 8 Figure 2.3 Housing characteristics by residence Figure 3.1 Percentage of currently married women who know of various contraceptive methods by residence Figure 3.2 Percentage of currently married women using contraceptive methods by residence Figure 3.3 Use of modern contraceptive methods before the birth of the first child by residence and age group (15-19 and 20-24) Figure 3.4 Source of supply for current users of modern contraceptive methods by residence Figure 3.5 Contact of nonusers of contraceptive methods with family planning providers by residence Figure 4.1 Percent distribution of currently married women age by desire for more children and residence Figure 5.1 Percentage of women who know of programmatically important ways to avoid HIV/AIDS by residence Figure 5.2 Percent distribution of currently married women age who have knowledge of various AIDS-related issues by residence Figure 5.3 Percentage of women who know a source for condoms and who used a condom during last sexual intercourse by residence v

6 EXECUTIVE SUMMARY The Family Planning and Reproductive Health Survey of 2003 (FPRHS03) was a sample survey representative of six districts in Malawi. These districts were Chitipa and Karonga in Northern Region, Ntchisi and Dowa in Central Region, and Chiradzulu and Mulanje in Southern Region. In three of these districts, Chitipa, Ntchisi, and Chiradzulu, the Population and Family Planning Project (PopFP) implemented a pilot project to test the feasibility of district-wide, community-based distribution of family planning and reproductive health services. Karonga, Dowa, and Mulanje served as control districts. PopFP did not carry out any interventions in these control districts. PopFP launched its pilot project in 1999 and completed it in PopFP carried out the Family Planning and Reproductive Health Survey of 2003 as an end-of-project survey designed to provide data to compare the pilot and control districts in terms of a number of family planning, reproductive health, and HIV/AIDS indicators. FPRHS03 covered 3,397 households, 1,703 in pilot districts and 1,694 in control districts. The survey interviewed 3,207 women aged 15-49, 1,615 in pilot districts and 1,592 in the control districts. Interviewing was done by 150 Health Surveillance Assistants (HSAs) during April and May, This report compares the prevalence of knowledge and practice of modern family planning methods and reproductive health norms in the pilot and control districts surveyed in The report also analyses changes in family planning and reproductive health knowledge and practice since 1999, when PopFP did a baseline Family Planning and Reproductive Health Survey at the beginning of the project. PopFP used the same sample designs and survey questionnaires in 1999 and Family Planning Knowledge of modern contraception is now almost universal in the pilot and control districts. In 2003, in both the pilot and control districts, almost all women aged reported that they knew of at least one modern method of contraception. Prevalence of this knowledge in FPRHS areas increased from 89 percent in the pilot districts and 93 percent in the control districts in 1999 to 97 percent in 2003 in both pilot and control areas. The most widely known methods are long-acting injectables, birth control pills, and the male condom. Contraceptive use has increased. The modern contraceptive prevalence rate (current use by currently married women aged of a modern family planning method) rose in the pilot districts from 24 percent in 1999 to 36 percent in In the control districts, the CPR increased less than half as much from 25 to 30 percent. In the pilot districts, there is also a move away from traditional contraception, with proportionately fewer women using less effective, traditional methods in 2003 than in By contrast, in the control districts, women reported using traditional methods at the same levels of prevalence as in Women are using modern contraceptives at younger ages and lower parity. Couples who want large families tend to use family planning at older ages after the birth of several children, if at all. Between 1999 and 2003, there was an increasing tendency for women to use contraception at younger ages, and after fewer births. In 2003, higher percentages of young respondents in particular reported using family planning at zero parity (before the birth of the first child). In the pilot districts, the percentage of women aged who had used contraception at zero parity almost doubled between 1999 and 2003 from 11 to 21 percent. In the control districts usage at zero parity for the age group rose by only 3 percentage points from 10 to 13 percent. vii

7 Sources of family planning methods. The vast majority of women in both the pilot and control districts continue to get their contraceptive methods from government institutions. There has also been a decline in the percentages of women reporting private sources in both pilot and control areas. However, between 1999 and 2003, in the pilot districts there has been a striking increase in respondents who reported community-based distribution agents (CBDAs) as a source of contraceptive supplies. Whereas only 1 percent cited CBDAs as a source of contraception in both the pilot and control districts in 1999, this figure rose to 24 percent in the pilot areas in In the control areas there was no significant change between 1999 and Promotion of CBDAs as a source of contraceptive supplies and family planning education has been a main strategy of the Population and Family Planning Project. Nonusers of family planning reported increased contact with family planning providers. In pilot districts, the percentage of women not using contraception who were not contacted by a family planning fieldworker and were not counselled at a health facility declined from 67 percent to 58 percent between 1999 and By contrast, in the control districts the percentage of nonusers reporting no contact and no counselling at facilities actually increased from 67 to 71 percent. Likewise, in the pilot districts, the proportion of nonusers reporting that they had been visited by a family planning fieldworker rose from 17 to 27 percent, whereas in the control districts it declined from 19 to 9 percent. More married women favour limiting family size. The proportion of women reporting that they want no more children increased slightly from 31 percent to 34 percent in the pilot districts and from 29 to 32 percent in the control districts between 1999 and HIV/AIDS Awareness of HIV/AIDS has been almost universal in both the pilot and control districts since Ninety-eight percent of respondents in the pilot districts, and 99 percent in control districts reported that they had heard of HIV or AIDS. In the baseline survey (1999), 98 percent of respondents in both the pilot and control areas were aware of HIV or AIDS. Knowledge of programmatically important ways to avoid HIV/AIDS has increased slightly since In 2003, 74 percent of women in the pilot districts were able to name three or more effective ways to avoid HIV infection compared with 71 percent in By contrast, in the control districts, there was a slight decrease between 1999 and 2003 in proportion of respondents who could name three or more preventive methods from 71 percent to 68 percent. In 1999 and 2003, in both the pilot and control districts, an additional one-fifth of women were able to name 2 effective preventive methods. In the pilot areas, in 2003, 91 percent of women knew at least 2 effective methods of prevention, compared with 88 percent in the control areas. Knowledge of issues related to transmission of the AIDS virus is widespread. People who have been personally affected by the AIDS epidemic in terms of knowing someone who has HIV or a person who has died of AIDS may be more cautious in their own behaviour and may be more sympathetic to persons who are infected. In 2003, 77 percent of respondents in the pilot districts knew someone with HIV infection or who had died of AIDS compared with 76 percent of those in the control districts. In 1999, 77 percent of respondents in the pilot areas were acquainted with infected persons or AIDS-related deaths compared with 70 percent of women in the control districts. Regarding knowledge of key means of HIV transmission, in 2003, 87 percent of respondents in both the pilot and control districts knew that a healthy-looking person can harbour HIV. Comparable percentages for 1999 were 86 percent for the pilot districts and 85 percent for controls. In 2003, 88 percent of women in the pilot districts were aware that HIV can be transmitted from mother to child compared with 85 percent in the control districts. In 1999, these percentages were 89 percent and 88 percent, respectively. viii

8 Knowledge of condom sources and usage during sexual intercourse. Knowing where to obtain condoms and using them during sexual intercourse are important in protecting against HIV infection. In the pilot districts, knowledge of at least one source for condoms remained constant at 74 percent between 1999 and By contrast, in the control districts, knowledge of one source declined from 71 to 62 percent. Usage of a condom during last sex increased between 1999 and 2003 from 12 to 17 percent in the pilot districts, while it remained constant among women in the control districts at 11 percent. ix

9 MALAWI TANZANIA Pilot districts (Chitipa, Ntchisi, Chiradzulu) Control districts (Karonga, Dowa, Mulanje) Mzuzu Lake Malawi ZAMBIA MOZAMBIQUE River e S hir (Kilometres) x

10 CHAPTER 1 INTRODUCTION 1.1 Geography, Population and Economy Malawi is bordered by Tanzania to the north and east, Mozambique to the south and east, and Zambia on the west. It is approximately 900 kilometres in length and ranges in width from 80 to 160 kilometres. It has a total area of 118,486 square kilometres, of which 94,276 are land. The remaining area consists mainly of Lake Malawi, which is about 475 kilometres long and runs down Malawi s eastern boundary with Tanzania and Mozambique. Malawi has three administrative areas the Northern Region with six districts, the Central Region with nine districts and the Southern Region with ten districts. Each district is further subdivided into Traditional Authorities (TAs) which are presided over by Traditional Chiefs. Each TA includes a number of villages. The village is the smallest administrative unit. For census enumeration purposes, Traditional Authorities are divided into enumeration areas (EAs). Malawi s climate is tropical continental with some maritime influences. Temperature and rainfall vary with proximity to Lake Malawi and altitude, which ranges from 37 metres, where the Shire River crosses into Mozambique, to 3,000 metres at the peak of Mount Mulanje. Malawi has had population censuses since The most recent were carried out in 1987 and Other recent sources of national population data in Malawi are the 1992 and 1993 National Sample Surveys of Agriculture, the 1992 Malawi Demographic and Health Survey, the 1996 Malawi Knowledge, Attitudes and Practices in Health Survey, and the 2000 Malawi Demographic and Health Survey. Table 1.1 shows demographic indicators derived from the last three national censuses. The 1998 Population and Housing Census enumerated a total population of 9.9 million compared with 8.0 million recorded by the 1987 census. This represents an intercensal growth rate of 24 percent or 2 percent per year. High population growth in Malawi is in large part due to a continued high fertility rate. The total fertility rate has declined from 7.6 in 1977 to 7.4 in 1987, and 6.5 percent in 1998 (Table 1.1), but it is still among the highest in Southern Africa. Rapid population growth is increasing pressure on natural resources and social services. Further growth in the population will reduce land availability per capita, and further increase the already high levels of malnutrition, poverty, and environmental degradation. To reduce the level of poverty and to improve the quality of life, the Government of Malawi adopted a National Population Policy (NPP) in The NPP includes strategies for improving the quality of life by means of reproductive health and family planning programmes, free universal education (including gender issues) in all development programmes, as well as creating employment and small scale business opportunities. The NPP set the following goals, to be achieved by 2002: reduction of the TFR to 5.4 children per woman, reduction of the infant mortality rate to 100 per 1000 live births, reduction of the child mortality rate to 150 per 1000, and a decline in the maternal mortality rate to less than 300 deaths per 100,000 live births. 1

11 Table 1.1 Demographic indicators Selected demographic indicators, Malawi, 1977, 1987, and 1998 national censuses Census year Indicator Population 5,547,460 7,988,507 9,933,868 Intercensal growth rate Total area (sq km) 118, , ,484 Land (sq km) 94,276 94,276 94,276 Density (population per sq km) Percentage of urban population Women of childbearing age as percentage of female population Sex ratio Crude birth rate Total fertility rate Crude death rate Infant mortality rate Life expectancy Male Female The Population and Family Planning Project As part of its strategies for reducing population growth, the Ministry of Health and Population, Government of Malawi, implemented the Population and Family Planning Project (PopFP). The objective of this project was to test the feasibility of a comprehensive, district-wide community-based distribution (CBD) approach to delivery of family planning services. Three pilot districts were selected for testing the feasibility of this approach. Each pilot district was paired with a control district for evaluation purposes. One pair was located in each of the three regions of Malawi. In Northern Region, the pilot district was Chitipa, while the control district was Karonga. In Central Region, the pilot was Ntchisi District and the control was Dowa District. In the South, Chiradzulu District was the pilot while Mulanje was the control. These six districts were chosen because they were among the least developed districts in Malawi. All six districts had poor access to primary health care services, including family planning. The expected outcome of the project was an increase in the contraceptive prevalence rate (CPR) for modern family planning methods. The objective of a higher CPR was to be achieved by means of 1) increased knowledge and approval of family planning, 2) increased demand for modern family planning services and 3) increased access to such services among men, women, and adolescents living in rural and underserved areas of Malawi. The project s key performance indicators included increasing the proportion of men and women with a positive attitude toward family planning to 70 percent and an increase in the CPR for modern methods to 28 percent. Since the programme was community based, its goal was to train about 100 community-based 2

12 distribution agents (CBDAs) and strive to retain at least 80 percent of them through provision of incentives. Another objective was to increase the average number of clients seen by each CBDA to 200 by the end of the project. Process indicators included the number of health workers trained to provide a wide range of reproductive and family planning services, the number of family planning clinics with adequate contraceptives, equipment and supplies, and the number of IEC messages developed and disseminated using a multimedia approach for purposes of increasing the use of modern family planning and reproductive health methods. 1.3 The Family Planning and Reproductive Health Surveys, 1999 and 2003 To establish benchmarks for project indicators, PopFP carried out a baseline Family Planning and Reproductive Health Survey (FPRHS99) in the three pilot districts and the three control districts in The results of the baseline survey were used to refine the target indicators for the project. The end-of-project survey carried in out 2003 (FPRHS03), which is analyzed in this report, was carried out to assess changes in the levels of the PopFP indicators since the baseline survey of The baseline and end-of-project surveys were designed to be used along with qualitative assessments to evaluate the extent to which PopFP has achieved its objectives. Since the PopFP was principally a rural-based intervention, FPRHS99 and FPRHS03 did not include the small part of the three pilot and three control district populations that were designated by the 1998 census as urban. FPRHS99 and FPRHS03 collected information on the following project indicators: Family Planning and Reproductive Health Indicators Contraceptive prevalence rate (CPR) for modern methods. The CPR for modern methods is the proportion of all women and currently married women (15-49) who are currently using a modern method of family planning. Sources of contraceptive methods. Women were asked where they last obtained their methods of contraception so that the survey could report the percentages of contraceptive users obtaining their family planning methods from various private and public sources. Approval of family planning. Women were asked whether they approved of family planning. Preferences about further childbearing. Women were asked if they wished to have another child, space their next birth, or stop childbearing. Contraceptive knowledge. Women were asked if they had ever heard of specific contraceptive methods. Knowledge of contraceptive sources. Women were asked to name places where contraceptives can be or were obtained. Knowledge of means to prevent HIV/AIDS. Women were asked about various aspects of HIV risk, risk avoidance, and condom use. Social and Economic Status Indicators Female education levels Housing characteristics and household facilities Prevalence of female head of households For many indicators, data were collected that would allow estimates to be produced for each of the three pilot districts (Chitipa, Ntchisi, and Chiradzulu) and the three control districts (Karonga. Dowa, and 1 Population and Family Planning Project, Ministry of Health and Population, and Macro International Inc Family Planning and Reproductive Health Survey Lilongwe, Malawi and Calverton, Maryland, USA: Ministry of Health and Population and Macro International. 3

13 Mulanje). For some indicators requiring larger sample sizes, a single estimate was produced for the pilot districts taken together and a single estimate for the control districts taken together. The FPRHS surveys were executed in conformance with conventional procedures so as to ensure comparability with the Malawi Demographic and Health Survey (MDHS) Organization of the Family Planning and Reproductive Health Survey 2003 The design of the end-of-project Family Planning and Reproductive Health Survey (FPRHS03) was the same as the design of the baseline FPRHS99. FPRHS03 was carried out in April, 2003 by the Population and Family Planning Project (PopFP) of the Ministry of Health and Population (MOHP). Sampling materials were made available by the National Statistical Office (NSO), Zomba, Malawi. Technical assistance was provided by the National Statistical Office and the Demographic and Health Research Division of ORC Macro, Calverton, Maryland, U. S. A. Funding for the survey was provided by PopFP under a loan agreement between the Ministry of Health and Population and the World Bank. 1.5 Sample Design The FPRHS03 covered the three pilot districts and three control districts of the PopFP. A systematic sample of 25 census enumeration areas was selected in each of the six districts, totalling 150 EAs for the survey: 75 in the control districts and 75 in the pilot districts. The selection of EAs was based on the 1998 national census, with the probability of EA selection being proportional to EA size. A separate household listing operation was not conducted prior to the FPRHS03 fieldwork. Instead, listings were carried out before interviewing in each EA by Health Surveillance Assistants (HSAs), who had been trained as survey interviewers. In a second stage of sampling, a systematic random sample of households was blindly drawn from household lists by the supervisors of the interviewers. The sampling interval for the sample draw for each EA was proportional to its size based on the results from the listing. All women aged 15 to 49 in the interviewed households were eligible for the survey. 1.6 Questionnaires Two questionnaires were used in the FPRHS03, a household questionnaire and a women s questionnaire (see Appendix B). Each questionnaire was composed of subsets of questions from the standard Demographic and Health Survey questionnaires plus some questions which captured indicators of special interest to the PopFP. The household questionnaire included a household schedule and questions on household facilities. The women s questionnaire contained sections on the respondent s background, reproduction, contraception, marriage and sexual activity, fertility preferences, and HIV/AIDS. 1.7 Training and Fieldwork Training of field staff for the survey was carried out in two phases. In the first phase, which took place in Lilongwe on April 7-11, 2003, district-level supervisors and some PopFP staff were trained in listing, interviewing, and supervision of interviewers. Training was done by senior survey managers from the National Statistical Office, Zomba, with help from the survey monitor from ORC Macro. In a second phase, on April 14-18, district supervisors, NSO officers, and PopFP staff trained HSAs at Thondwe (Southern Region), Mponela (Central Region), and Karonga (Northern Region). Again training focused on listing, questionnaires, and field procedures. Fieldwork commenced on 21 April and was completed on 17 May, Most of the HSAs who acted as interviewers worked in the enumeration areas to which they were posted as regular employees of the MOHP. In some cases, it was necessary to utilize the services of HSAs who were from outside the EAs in 4

14 which they interviewed survey respondents. The work of the HSAs was supervised by nursing and environmental health staff serving in the pilot and control districts and by the cognizant District Family Planning Coordinators. Table 1.2 shows response rates for the FPRHS03. A total of 3,450 households were selected in the sample. Of these, 3,447 were occupied as of the survey date: 1,726 in the pilot districts and 1,721 in the control districts. A total of 1,703 households were interviewed in the pilot districts and 1,694 in the control districts, for a total of 3,397 interviewed households. The overall household response rate was 99 percent: 99 percent in the pilot districts and 98 percent in the control districts. The main reason for not interviewing a household was failure to find an eligible household respondent, despite repeated visits by the interviewer. The number of eligible women (aged 15-49) identified in the household schedule was 1,647 in the pilot districts and 1,616 in the control districts, for a total of 3,263 eligible respondents. Of these eligible women, 1,615 were successfully interviewed in the pilot districts (98 percent response rate) and 1,592 in the control districts (99 percent response). The overall response rate for eligible women was 98 percent. The main reason for not interviewing an eligible woman was failure to find her despite repeated callbacks. All questionnaires were returned to the PopFP office for processing. Office editing, coding and data entry were carried out by PopFP under the supervision of the Monitoring and Evaluation Officer. Data entry and editing were done using CSPRO, survey database software developed by the Demographic and Health Surveys Programme (ORC Macro), and the United States Bureau of the Census. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, by residence (pilot or control district), Malawi 2003 Residence Pilot Control Result districts districts Total Household interviews Number sampled 1,726 1,724 3,450 Number occupied 1,726 1,721 3,447 Number interviewed 1,703 1,694 3,397 Household response rate Individual interviews Number of eligible women 1,647 1,616 3,263 Number interviewed 1,615 1,592 3,207 Eligible woman response rate

15 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS The purpose of this chapter is to provide a descriptive summary of selected socioeconomic characteristics of the household population and individual survey respondents. Data on age, sex, residence (pilot or control district), household composition, household characteristics, and respondent background information are presented. These data can be used in two important ways. First, characteristics of the surveyed population provide a context for the interpretation of key findings on reproductive health behaviour. Second, the socioeconomic data allow for examination of the comparability of the pilot and the control districts selected by the PopFP. 2.1 Household Population The FPRHS03 household questionnaire provides information on the demographic and social characteristics of all usual residents of the sample households, and visitors who had spent the previous night in the household Age-Sex Composition The distribution of the FPRHS03 household population is shown in Table 2.1 by five-year age groups, according to sex and residence (pilot or control district). The age and sex distribution of the pilot and control groups is shown in population pyramids in Figures 2.1 and 2.2. The age-sex structures are comparable, showing the broadbased pattern that is typical of populations with a history of high fertility. If, as expected, fertility begins to decline, the base of the pyramids should be narrowed by the birth of fewer and fewer children. The age-sex distribution of the household population as reported in the 2003 survey is very similar to that reported in the 1999 baseline survey. 3 The bump at age group among women could be due to interviewers shifting some women out of the age range of eligibility for the individual interview to lighten the work load of interviewing. The same behaviour may explain the deficit of women aged relative to those aged A household is a group of related and unrelated persons who live together in the same dwelling unit(s), who acknowledge one adult male or female as head of household, who share the same housekeeping arrangements, and are considered as one unit. A member of the household is any person who usually lives in the household and a visitor is someone who is not a usual member of the household but had slept in the household the night before the interview. The household population presented in this chapter includes, unless otherwise stated, all usual members of the household who slept in the household the night before the survey and visitors (de facto population). 3 Population and Family Planning Project (PopFP), Ministry of Health and Population [Malawi] and Macro International Inc. [MI] Family Planning and Reproductive Health Survey: A Baseline Survey of Selected Districts in Malawi, Lilongwe, Malawi and Calverton, Maryland (USA): PopFP and MI, p. 7. 6

16 Table 2.1 Household population by age and sex Percent distribution of the de facto household population by five-year age groups, according to sex and residence (pilot or control district), Malawi 2003 Pilot districts Control districts Both Both Age Male Female sexes Male Female sexes Missing / don't know Total Number 3,894 4,087 7,981 3,895 4,103 7,998 7

17 Figure 2.1 Population Pyramid, Pilot Districts, Malawi 2003 Age Male Female Percent Figure 2.2 Population Pyramid, Control Districts, Malawi 2003 Age Male Female Percent 8

18 2.1.2 Household Composition Table 2.2 presents the percent distribution of households in the sample by female headship, number of usual household members, and mean household size, tabulated according to residence (pilot or control district). The prevalence of female headship is similar in the pilot and the control districts (27 and 26 percent) and is comparable to that recorded for rural areas by the national Malawi Demographic and Health Survey of 2000 (28 percent). 4 The average number of persons residing in a household in both the pilot and the control districts is about five. The 1999 baseline survey reported a female headship prevalence of 25 percent in the pilot districts compared with 24 percent in the control districts Housing Characteristics Table 2.2 Household composition Percent distribution of households by female headship and size, Malawi 2003 Residence Pilot Control Characteristic districts districts Female headship (%) Number of usual members Total Information on the characteristics of the interviewed Mean size households is given in Table 2.3. The physical characteristics of housing give an indication of social and economic status and are also related to the environmental exposure of household members to disease-causing agents. Fifty-three percent of the pilot households reported owning a radio, while for the control districts this figure was almost the same at 55 percent. In 1999, reported prevalence of radios among households was 41 percent for the pilot districts and 43 percent in the control districts. 6 Access to radios has increased by 12 percentage points in the study area during the last three and a half years. The proximity of a household to a water source is an important factor in determining patterns of water use. The FPRHS03 asked respondents to report how long it takes to reach the principal water source and return. In the pilot districts, 33 percent of households reported that it takes less than 15 minutes to make this trip, while in the control districts 39 percent reported being able to fetch water in less than 15 minutes. A large majority of households use pit toilets or latrines, although 27 percent of households in Dowa and 28 percent in Karonga reported no latrine or pit toilet at all. Most households in the studied districts have unfinished floors of earth or sand. In general, the pilot districts are similar to the control districts in terms of household characteristics and amenities. This suggests populations of comparable socioeconomic development. As an exception, the overall picture of the pilot districts is that they have greater access to pit latrine facilities. In the case of pit latrines, the difference in prevalence of access was marked: 90 percent of the pilot households reported access to these facilities compared with 77 percent of the control households. 4 National Statistical Office [Malawi] and ORC Macro Malawi Demographic and Health Survey PFPP and MI, p Ibid., p. 9. 9

19 Table 2.3 Housing characteristics Percent distribution of households by housing characteristics and amenities, according to district and residence (pilot or control district), Malawi 2003 District Residence Chirad- Background Chitipa Karonga Ntchisi Dowa zulu Mulanje Pilot Control characteristic (P) (C) (P) (C) (P) (C) districts districts Radio Have radio No radio Missing Total Time to water source and back Percent less than 15 minutes Sanitation facility Flush toilet Pit toilet/latrine No facility, bush, field Other Missing Total Flooring Earth, unfinished Cement, other finished Other Missing Total Number ,702 1,695 Note: Source of household drinking water information is omitted from this table because of inconsistent responses for this variable. Figure 2.3 compares changes in selected household characteristics in the pilot and control districts between 1999 and In terms of pit toilets and latrines, there was little change but, compared with 1999, the pilot areas continued to enjoy greater access to these facilities. Access to radio and, implicitly, exposure to family planning and public health messages increased by the same amount in the pilot and control districts. In the pilot areas, the percentage of households reporting that it took them less than 15 minutes to get water and return to the household increased from 28 percent in 1999 to 33 percent in In the control areas the percentage of households reporting that it took less than 15 minutes to fetch water increased from 28 percent in 1999 to 39 percent in

20 Figure 2.3 Housing Characteristics by Residence (Pilot or Control District) Time to to water source and back (percentage and back less (Percentage than 15 minutes) less tha Access to pit toilet or latrine Pilot '03 Control '03 Pilot '99 Control '99 Access to radio 2.2 Characteristics of Respondents Percent Background characteristics of the 3,207 women aged who were interviewed in the survey appear in Table 2.4. There are no marked differences in age structure across districts, and the age structure of respondents in the 2003 survey is similar in that of the respondents to the 1999 survey. 7 The proportion of women who reported that they were currently married ranges from 76 percent in Ntchisi to 50 percent in Chiradzulu. Sixty-nine percent of women living in the control districts were reported as married, compared with 64 percent in the pilot districts. The southern districts of Mulanje and Chiradzulu reported lower percentages of married women than the other districts and higher proportions of women in consensual unions. The proportion of women who reported either that they were married or in a consensual union also favoured the control districts, with 77 percent of women in the control districts reporting either marriage or informal union compared with 72 percent in the pilot districts. In 1999, 76 percent of respondents in the pilot districts and 75 percent in the control districts reported that they were married or in union. In the rest of this report, the term currently married includes both formal and informal (consensual) unions. A much smaller percentage of women in the Northern Region s Chitipa and Karonga districts reported that they had no formal education than in the other districts. In 1999, as in 2003, Chitipa (14 percent) and Karonga (13 percent) surpassed all other districts in having the lowest prevalence of respondents with no education. 8 When the pilot and the control districts are viewed as groups, the proportion of women reporting that they had no formal education was slightly higher in the control districts (22 percent compared with 18 percent for the pilot districts). Very few respondents had any post-secondary education. 7 Ibid., p Ibid. 11

21 Table 2.4 Respondent background characteristics Percent distribution of women by age, marital status, and education, according to district and residence (pilot or control district), Malawi 2003 District Residence Chirad- Background Chitipa Karonga Ntchisi Dowa zulu Mulanje Pilot Control characteristic (P) (C) (P) (C) (P) (C) districts districts Age Marital status Never married Married Consensual union Widowed Divorced Separated Education No education Primary Secondary Post-secondary Number of women ,615 1,592 12

22 CHAPTER 3 FERTILITY REGULATION This chapter presents the FPRHS03 results regarding various aspects of contraceptive knowledge, attitudes, and behaviour. The chapter summarizes the following key indicators of the PopFP: prevalence of knowledge of contraceptive methods, ever use of contraceptive methods, current use of contraceptive methods, sources of supply for current users, contact of nonusers with family planning providers, and attitudes of women toward family planning. 3.1 Knowledge of Contraceptive Methods One of the objectives of the FPRHS03 was to collect information on the extent of knowledge of family planning methods among women aged Individuals who are adequately informed about their options regarding methods of contraception are better able to develop an approach to fertility that is in keeping with the best interests of their families. Information on knowledge of contraception was collected by asking respondents to name the ways by which a couple can delay or avoid pregnancy. If a respondent failed to mention a particular method spontaneously, the interviewer described the method and asked if she recognized it. Table 3.1 shows the percent distribution of all women, currently married women, and sexually active and inactive unmarried women by knowledge of contraceptive methods. Knowledge of family planning methods is quite high with 97 percent of respondents in both the pilot districts and the control districts knowing at least one method of family planning. Again, in both the pilot and control districts, 97 percent of all respondents know at least one modern method of contraception. As might be expected, higher levels of knowledge of modern methods were also reported for currently married women (98 percent for both the pilot and control districts) and sexually active unmarried women (96 percent in the pilot districts and 100 percent in the control districts). Knowledge of at least one modern method was also widespread among unmarried women who were not sexually active (96 percent in the pilot districts and 95 percent in the control districts). Among married and unmarried women, for both the pilot and the control districts, injectables, the pill, and the male condom were the most widely known methods of family planning. More than 90 percent of women in the pilot and the control districts have heard of injectables and the pill, while knowledge of the male condom is slightly lower. Just over three-fourths of women have heard of female sterilisation, with knowledge being consistently higher in the control districts than in the pilot districts. Around percent of all women know of the IUD and male sterilisation. Among currently married women, knowledge of male sterilisation is higher in the pilot districts, while among unmarried, sexually active women and unmarried sexually inactive women, there is little difference between the pilot and control areas. In the pilot districts, the mean number of methods known by currently married women is 7.0 (up from 5.1 in 1999), while in the control districts the mean number of methods known is 6.3 (up from 5.9 in 1999). Figure 3.1 shows the percentage of currently married women who know of contraceptive methods for both the FPRHS99 baseline and the FPRHS03 end-of-project surveys. Knowledge of any modern method rose from 92 percent in the pilot districts and 95 percent in the control districts in 1999 to 98 percent in both the pilot and control districts in This represents a 6 percentage point increase in the pilot districts where PopFP programmes were implemented, compared with a 3 percentage point increase in the control districts. For all modern methods, increases in knowledge between 1999 and 2003 were greater in the pilot districts than in the control districts. 13

23 Table 3.1 Knowledge of contraceptive methods Percentage of all women, currently married women, sexually active unmarried women, and sexually inactive unmarried women, who know specific contraceptive methods, by residence (pilot or control district), Malawi 2003 Unmarried women Currently Not All women married women Sexually active sexually active Method Pilot Control Pilot Control Pilot Control Pilot Control Any method (100.0) Any modern method (100.0) Pill (76.7) IUD (36.7) Injectables (90.0) Diaphragm/cervical cap (16.7) Foam/jelly (30.0) Female condom (40.0) Male condom (80.0) Female sterilisation (76.7) Male sterilisation (50.0) Implants (30.0) Emergency contraception (26.7) Lactational amenorrhea (LAM) (43.3) Any traditional method (50.0) Periodic abstinence (43.3) Withdrawal (36.7) Other (10.0) Mean number of modern methods known (5.5) Number of women 1,615 1,592 1,168 1, Note: Figures in parentheses are based on cases. 14

24 Figure 3.1 Percentage of Currently Married Women Who Know of Various Contraceptive Methods by Residence (Pilot or Control District) 98 Any modern method Any traditional method Injectables Pill Male condom Female sterilisation Pilot '03 Control '03 Pilot '99 Control '99 Percent Table 3.2 shows knowledge of contraceptive methods among currently married women by background characteristics as reported in the FPRHS03. In both the pilot and the control districts, women aged (women in their most active childbearing years or having recently passed through these years) tend to be more familiar with at least one modern method of family planning than women age 15-19, but the difference is small. Table 3.2 Knowledge of contraceptive methods among currently married women by background characteristics Percentage of currently married women who know at least one contraceptive method and who know at least one modern contraceptive method, by age, education, and residence (pilot or control district), Malawi 2003 Knows Knows any Number any method modern method of women Background characteristic Pilot Control Pilot Control Pilot Control Age Education No education Primary Secondary Total ,168 1,224 15

25 A woman s knowledge of modern family planning methods increases with increasing level of education in both the pilot and the control districts, but again the differences are small because knowledge is so widespread. By level of education, there was no difference in knowledge of modern methods between the pilot and the control districts. 3.2 Ever Use of Contraception All women interviewed in the FPRHS03 who said that they had heard of at least one family planning method were asked if they had ever used a method for delaying or preventing pregnancy. Table 3.3 shows the proportion of women who have ever used contraception by method and residence (pilot or control district). Among currently married women, the level of ever use of any family planning method in the pilot districts (72 percent) is similar to that in the control districts (70 percent). As expected, ever use of family planning is lower among unmarried women than married women except for the use of condoms, the most commonly used method among unmarried women. Table 3.3 Ever use of contraception among women who know of at least one method Percentage of all women, currently married women, and sexually active unmarried women who have ever used contraception, by method and residence (pilot or control district), Malawi 2003 Modern method Traditional method Using Dia- Female Male Any any Any phragm/ Female Male steri- steri- tradi- Periodic Number meth- modern Inject- cervical Foam/ con- con- lisa- lisa- Im- Emer- tional absti- With- of District od method Pill IUD ables cap jelly dom dom tion tion plant gency LAM method nence drawal Other women ALL WOMEN Pilot ,564 Control ,542 CURRENTLY MARRIED WOMEN Pilot ,146 Control ,201 SEXUALLY ACTIVE UNMARRIED WOMEN Pilot Control (43.3) (43.3) (20.0) (0.0) (20.0) (0.0) (0.0) (3.3) (23.3) (3.3) (0.0) (0.0) (3.3) (6.7) (13.3) (10.0) (6.7) (0.0) 30 Note: Figures in parentheses are based on cases. LAM = Lactional amenorrhea method Among all women, ever use of any modern method is more widely reported in the pilot districts (57 percent) than in the controls (50 percent). For currently married women, 63 percent reported ever use of modern methods in the pilot districts compared with 55 percent in the control districts. Among all women the most commonly reported modern method ever used was injectables, followed by the male condom and the pill. Ever use of injectables was reported by 33 percent of all women in both the pilot and control districts, and 38 percent of married women in both the pilot and control districts. Ever use of injectables among sexually active unmarried women was 17 percent in the pilot districts and 20 percent in the control districts, a small difference. However, the sample size for sexually active, unmarried respondents was small (76 in pilot districts and 30 in the control districts). As expected, ever use of male condoms is more common among sexually active unmarried women than it is among married women. In the pilot districts, ever use of male condoms, is 26 percent for currently mar- 16