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

This report presents the findings of the 2003 Family Planning and Reproductive Health Survey (FPRHS03), an end- of project study of selected districts in Malawi where a community-based family planning delivery system was pi- loted 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: 1 724-981; fax: 1 724-223; e-mail: [email protected]). 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, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705-3119 (tel: 301-572- 0200; fax: 301-572-0999; e-mail: [email protected]; internet: www.measuredhs.com).

Recommended citation:

Population and Family Planning Project (PopFP), Ministry of Health and Population [Malawi] and ORC Macro. 2003. 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. CONTENTS

TABLES AND FIGURES ...... v EXECUTIVE SUMMARY ...... vii MAP OF MALAWI ...... x

CHAPTER 1 INTRODUCTION...... 1 1.1 Geography, Population and Economy ...... 1 1.2 The Population and Family Planning Project ...... 2 1.3 The Family Planning and Reproductive Health Surveys, 1999 and 2003 ...... 3 1.4 Organization of the Family Planning and Reproductive Health Survey 2003...... 4 1.5 Sample Design...... 4 1.6 Questionnaires ...... 4 1.7 Training and Fieldwork...... 4

CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS ...... 6 2.1 Household Population...... 6 2.1.1 Age-Sex Composition...... 6 2.1.2 Household Composition...... 9 2.1.3 Housing Characteristics ...... 9 2.2 Characteristics of Respondents ...... 11

CHAPTER 3 FERTILITY REGULATION...... 13 3.1 Knowledge of Contraceptive Methods ...... 13 3.2 Ever Use of Contraception...... 16 3.3 Current Use of Contraceptive Methods ...... 17 3.4 Number of Children at First Use of Contraception...... 19 3.5 Source of Family Planning Methods...... 20 3.6 Contact of Nonusers of Family Planning with Family Planning Providers ...... 23 3.7 Attitudes of Women Toward Family Planning...... 25

CHAPTER 4 FERTILITY PREFERENCES ...... 27 4.1 Fertility Preferences of Currently Married Women by Number of Living Children...... 27

CHAPTER 5 AIDS KNOWLEDGE AND PREVENTION ...... 29 5.1 Knowledge of HIV/AIDS ...... 29 5.2 Knowledge of Ways to Avoid HIV/AIDS ...... 30 5.3 Knowledge of Programmatically Important Ways to Avoid AIDS ...... 30 5.4 Knowledge of Issues Related to Transmission of the AIDS Virus...... 32 5.5 Knowledge of a Source for Condoms...... 33 5.6 Use of Condoms during Last Sexual Intercourse...... 34

APPENDIX A: FAMILY PLANNING AND REPRODUCTIVE HEALTH SURVEY STAFF, 2003...... 37

APPENDIX B: QUESTIONNAIRES...... 41

iii 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...... 10 Table 2.4 Respondent background characteristics...... 12 Table 3.1 Knowledge of contraceptive methods ...... 14 Table 3.2 Knowledge of contraceptive methods among currently married women by background characteristics...... 15 Table 3.3 Ever use of contraception among women who know of at least one method...... 16 Table 3.4 Current use of contraception...... 18 Table 3.5 Number of children at first use of contraception for ever-married women ...... 20 Table 3.6 Source of supply among current users...... 21 Table 3.7 Contact of nonusers with family planning providers...... 24 Table 3.8 Approval of family planning ...... 26 Table 4.1 Fertility preferences of currently married women by number of living children ...... 27 Table 5.1 General knowledge of HIV/AIDS ...... 29 Table 5.2 Knowledge of ways to avoid HIV/AIDS...... 30 Table 5.3 Knowledge of specific ways to avoid getting the AIDS virus...... 31 Table 5.4 Percentage of women who know of HIV/AIDS by responses to questions on various AIDS-related issues by residence ...... 32 Table 5.5 Knowledge of condoms and sources ...... 34 Table 5.6 Use of condoms ...... 35

Figure 2.1 Population pyramid, pilot districts...... 8 Figure 2.2 Population pyramid, control districts...... 8 Figure 2.3 Housing characteristics by residence...... 11 Figure 3.1 Percentage of currently married women who know of various contraceptive methods by residence...... 15 Figure 3.2 Percentage of currently married women using contraceptive methods by residence ...... 19 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) ...... 20 Figure 3.4 Source of supply for current users of modern contraceptive methods by residence...... 22 Figure 3.5 Contact of nonusers of contraceptive methods with family planning providers by residence...... 25 Figure 4.1 Percent distribution of currently married women age 15-49 by desire for more children and residence ...... 28 Figure 5.1 Percentage of women who know of programmatically important ways to avoid HIV/AIDS by residence...... 32 Figure 5.2 Percent distribution of currently married women age 15-49 who have knowledge of various AIDS-related issues by residence ...... 33 Figure 5.3 Percentage of women who know a source for condoms and who used a condom during last sexual intercourse by residence ...... 34

v EXECUTIVE SUMMARY

The Family Planning and Reproductive Health Survey of 2003 (FPRHS03) was a sample survey repre- sentative 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 2003.

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 Assis- tants (HSAs) during April and May, 2003.

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 2003. 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 2003.

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 15-49 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 15-49 of a modern family planning method) rose in the pilot districts from 24 percent in 1999 to 36 percent in 2003. 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 pro- portionately fewer women using less effective, traditional methods in 2003 than in 1999. By contrast, in the control districts, women reported using traditional methods at the same levels of prevalence as in 1999.

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 15-19 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 15-19 age group rose by only 3 percentage points from 10 to 13 percent.

vii 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 2003. In the control areas there was no significant change between 1999 and 2003. 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 2003. 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 2003.

HIV/AIDS

Awareness of HIV/AIDS has been almost universal in both the pilot and control districts since 1999. 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 1999. 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 1999. 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 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 2003. 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 MALAWI

TANZANIA

Pilot districts (Chitipa, Ntchisi, Chiradzulu) Lake Mzuzu Malawi Control districts (Karonga, Dowa, Mulanje)

ZAMBIA

MOZAMBIQUE

r e v i

R ir e S h

60 0 60

(Kilometres)

x 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 Tradi- tional 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 Au- thorities 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 1891. The most recent were carried out in 1987 and 1998. Other recent sources of national population data in Malawi are the 1992 and 1993 National Sample Sur- veys 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 1994. 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 Table 1.1 Demographic indicators

Selected demographic indicators, Malawi, 1977, 1987, and 1998 national censuses –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Census year –––––––––––––––––––––––––––––– Indicator 1977 1987 1998 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Population 5,547,460 7,988,507 9,933,868 Intercensal growth rate 2.9 3.2 2.0 Total area (sq km) 118,484 118,484 118,484 Land (sq km) 94,276 94,276 94,276 Density (population per sq km) 59 85 105 Percentage of urban population 8.5 10.7 14.0 Women of childbearing age as percentage of female population 45.1 44.2 47.2 Sex ratio 93 94 96 Crude birth rate 48.3 41.2 37.9 Total fertility rate 7.6 7.4 6.5 Crude death rate 25.0 14.1 25.0 Infant mortality rate 165 159 121

Life expectancy

Male 39.2 41.4 40.0 Female 42.4 44.6 44.0

1.2 The Population and Family Planning Project

As part of its strategies for reducing population growth, the Ministry of Health and Population, Govern- ment 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 Ma- lawi. 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 under- served 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 distribution agents (CBDAs) and strive to retain at least 80 percent of them through provision of incen- tives. 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 Repro- ductive Health Survey (FPRHS99) in the three pilot districts and the three control districts in 1999.1 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 1999. 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. 2000 Family Planning and Reproductive Health Survey 1999. Lilongwe, Malawi and Calverton, Maryland, USA: Minis- try of Health and Population and Macro International. 3 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 Ma- lawi Demographic and Health Survey (MDHS) 2000.

1.4 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 mate- rials 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, list- ings 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 in- terval 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 Demo- graphic and Health Survey questionnaires plus some questions which captured indicators of special inter- est 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 Na- tional 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, 2003. 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 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 Plan- ning 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 call- backs.

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 98.7 98.4 98.5

Individual interviews Number of eligible women 1,647 1,616 3,263 Number interviewed 1,615 1,592 3,207

Eligible woman response rate 98.1 98.5 98.3

5 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.2

2.1.1 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 50-54 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 15-19 relative to those aged 10-14.

2 A household is a group of related and unrelated persons who live together in the same dwelling unit(s), who ac- knowledge 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 Inter- national Inc. [MI] 2000. Family Planning and Reproductive Health Survey: A Baseline Survey of Selected Districts in Malawi, 1999. Lilongwe, Malawi and Calverton, Maryland (USA): PopFP and MI, p. 7. 6 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 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 0-4 17.5 15.4 16.4 17.2 17.2 17.2 5-9 16.4 16.2 16.3 17.7 16.6 17.1 10-14 14.6 16.8 15.7 14.4 15.4 14.9 15-19 11.4 8.5 9.9 9.3 8.0 8.6 20-24 7.7 10.3 9.0 7.8 9.6 8.7 25-29 6.9 6.4 6.6 7.1 7.5 7.3 30-34 5.0 5.4 5.2 5.9 5.2 5.5 35-39 4.6 4.6 4.6 4.9 4.4 4.7 40-44 3.1 3.1 3.1 3.3 3.0 3.2 45-49 2.7 2.1 2.4 3.0 1.7 2.3 50-54 2.3 4.2 3.3 2.5 3.7 3.1 55-59 1.9 2.1 2.0 1.6 2.2 1.9 60-64 1.8 1.7 1.8 1.6 1.5 1.5 65-69 1.5 1.1 1.3 1.4 1.6 1.5 70-74 1.2 1.1 1.2 0.9 1.0 1.0 75-79 0.5 0.3 0.4 0.6 0.7 0.6 80 + 0.5 0.6 0.5 0.5 0.4 0.5 Missing / don't know 0.4 0.0 0.2 0.4 0.3 0.4

Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,894 4,087 7,981 3,895 4,103 7,998

7 Figure 2.1

Population Pyramid, Pilot Districts, Malawi 2003

Age

80+ 75-79 70-74 65-69 60-64 55-59 Male Female 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4

108 6 4 2 0 0246810

Percent

Figure 2.2 Population Pyramid, Control Districts, Malawi 2003

Age 80+ 75-79 70-74 65-69 60-64 55-59 Male Female 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4

108 6 4 2 0 0246810

Percent

8 2.1.2 Household Composition Table 2.2 Household composition Table 2.2 presents the percent distribution of households in the sample by female headship, number of usual Percent distribution of households by female head- household members, and mean household size, tabulated ship and size, Malawi 2003 –––––––––––––––––––––––––––––––––––––––––––– according to residence (pilot or control district). The Residence prevalence of female headship is similar in the pilot and ––––––––––––––––– the control districts (27 and 26 percent) and is Pilot Control comparable to that recorded for rural areas by the Characteristic districts districts –––––––––––––––––––––––––––––––––––––––––––– national Malawi Demographic and Health Survey of Female headship (%) 27.0 25.5 2000 (28 percent).4 The average number of persons residing in a household in both the pilot and the control Number of usual members 1 5.1 5.6 districts is about five. 2 11.6 11.6 3 17.6 16.9 The 1999 baseline survey reported a female headship 4 18.5 16.9 prevalence of 25 percent in the pilot districts compared 5 13.7 15.5 5 6 11.8 11.9 with 24 percent in the control districts. 7 10.0 9.6 8 5.5 5.5 2.1.3 Housing Characteristics 9 + 6.3 6.4 Total 100.0 100.0

Information on the characteristics of the interviewed Mean size 4.7 4.7 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. 2001. Malawi Demographic and Health Survey 2000. 5 PFPP and MI, p. 8. 6 Ibid., p. 9. 9 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 46.7 53.8 55.3 47.5 57.1 62.2 53.1 54.5 No radio 53.3 46.0 44.7 52.3 42.2 37.4 46.7 45.3 Missing 0.0 0.2 0.0 0.2 0.7 0.4 0.2 0.2

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Time to water source and back Percent less than 15 minutes 29.9 33.7 32.8 40.5 35.9 41.8 32.8 38.6

Sanitation facility Flush toilet 0.5 0.0 0.7 0.0 1.2 0.2 0.8 0.1 Pit toilet/latrine 94.7 71.0 83.0 72.3 90.9 87.0 89.5 76.6 No facility, bush, field 4.7 28.3 16.0 27.2 6.2 11.8 8.9 22.5 Other 0.0 0.0 0.2 0.0 0.7 0.2 0.3 0.1 Missing 0.0 0.7 0.2 0.5 1.1 0.9 0.4 0.7

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Flooring Earth, unfinished 93.8 92.3 97.5 93.9 84.0 79.7 91.8 88.7 Cement, other finished 6.2 7.7 2.5 5.3 15.5 19.7 8.0 10.8 Other 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.1 Missing 0.0 0.0 0.0 0.9 0.5 0.4 0.2 0.4

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 569 572 564 570 569 553 1,702 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 2003. 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 2003. 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 2003.

Figure 2.3

Housing Characteristics by Residence (Pilot or Control District)

TimeTime to to water water source source and back (percentageand back less(Percentage than 15 minutes) less tha

Pilot '03 Access to pit toilet Control '03 or latrine Pilot '99 Control '99

Access to radio

0 20406080100 Percent

2.2 Characteristics of Respondents

Background characteristics of the 3,207 women aged 15-49 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. 10. 8 Ibid. 11 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 15-19 24.3 20.7 17.7 20.5 19.0 20.5 20.5 20.5 20-24 22.4 22.5 25.8 25.0 27.0 24.8 25.0 24.1 25-29 15.6 18.6 14.7 17.4 18.0 18.6 16.0 18.2 30-34 12.5 18.5 14.3 12.2 14.8 10.8 13.8 13.9 35-39 12.3 9.0 11.9 11.3 9.0 13.3 11.1 11.2 40-44 8.9 6.8 9.1 8.8 7.0 7.2 8.4 7.6 45-49 4.1 3.9 6.4 4.9 5.2 4.8 5.2 4.5

Marital status Never married 15.2 7.9 14.2 16.3 13.6 7.0 14.4 10.4 Married 64.1 73.1 76.2 73.0 49.6 61.1 63.6 69.2 Consensual union 7.4 7.4 1.3 2.8 18.2 13.2 8.7 7.7 Widowed 3.1 3.0 2.3 1.9 5.4 3.7 3.5 2.8 Divorced 1.5 2.0 1.9 1.9 5.8 7.0 3.0 3.6 Separated 4.1 3.9 1.9 3.2 3.6 3.1 3.2 3.4

Education No education 9.7 10.5 24.9 30.2 21.6 25.5 18.4 22.0 Primary 77.6 78.8 66.4 63.2 64.4 64.2 69.8 68.8 Secondary 12.5 10.7 8.5 6.6 13.8 9.9 11.6 9.0 Post-secondary 0.2 0.0 0.2 0.0 0.2 0.4 0.2 0.1

Number of women 585 542 530 533 500 517 1,615 1,592

12 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 15-49. Individuals who are adequately informed about their op- tions regarding methods of contraception are better able to develop an approach to fertility that is in keep- ing 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). Knowl- edge 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 50-60 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 2003. 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 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 96.8 96.9 98.1 98.1 96.2 (100.0) 96.0 95.5

Any modern method 96.7 96.7 97.9 98.0 96.2 (100.0) 96.0 95.0 Pill 90.1 90.1 93.3 93.3 82.3 (76.7) 89.8 89.7 IUD 63.2 56.1 69.0 61.3 57.0 (36.7) 56.2 48.3 Injectables 91.7 93.2 94.9 96.0 86.1 (90.0) 88.7 89.3 Diaphragm/cervical cap 23.7 16.1 26.4 15.5 17.7 (16.7) 19.7 22.3 Foam/jelly 30.3 20.9 33.6 22.1 21.5 (30.0) 27.0 22.3 Female condom 48.4 38.1 50.9 39.5 43.0 (40.0) 47.8 40.9 Male condom 88.7 86.4 89.7 88.7 88.6 (80.0) 88.7 86.0 Female sterilisation 76.0 80.2 80.8 83.9 58.2 (76.7) 71.2 76.4 Male sterilisation 58.5 50.3 63.0 52.5 48.1 (50.0) 53.3 52.1 Implants 64.4 47.2 69.7 51.6 58.2 (30.0) 57.7 40.1 Emergency contraception 23.2 22.5 24.9 22.7 15.2 (26.7) 23.0 25.2

Lactational amenorrhea (LAM) 43.7 41.8 47.8 43.9 24.1 (43.3) 38.7 40.1

Any traditional method 62.5 64.2 68.4 68.5 40.5 (50.0) 55.8 60.7 Periodic abstinence 38.6 42.3 41.2 44.7 21.5 (43.3) 38.7 39.7 Withdrawal 46.2 45.5 51.0 49.3 26.6 (36.7) 43.8 42.1 Other 20.3 22.4 23.8 25.1 13.9 (10.0) 12.8 18.2

Mean number of modern methods known 6.6 6.0 7.0 6.3 5.8 (5.5) 6.2 5.9

Number of women 1,615 1,592 1,168 1,224 79 30 274 242 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Figures in parentheses are based on 25-49 cases.

14 Figure 3.1 Percentage of Currently Married Women Who Know of Various Contraceptive Methods by Residence (Pilot or Control District)

98 98 Any modern method 92 95 68 69 Any traditional method 59 69 95 96 Pilot '03 Injectables 88 91 Control '03 93 Pilot '99 93 Pill 86 Control '99 90 90 89 Male condom 81 84 81 84 Female sterilisation 62 75 0 20406080100

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 20-49 (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 15-19 95.8 94.7 95.8 94.7 119 151 20-24 97.5 98.1 97.5 98.1 319 321 25-29 99.1 99.2 99.1 99.2 223 257 30-34 98.4 100.0 98.4 99.5 185 195 35-39 99.4 98.0 98.7 98.0 155 148 40-44 97.2 97.9 96.3 97.9 107 94 45-49 100.0 96.6 98.3 96.6 60 58

Education No education 97.1 97.0 96.3 97.0 242 304 Primary 98.2 98.4 98.1 98.3 831 834 Secondary+ 100.0 98.8 100.0 98.8 95 86

Total 98.1 98.1 97.9 98.0 1,168 1,224

15 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 65.3 56.6 18.9 1.2 32.9 0.2 1.3 0.5 24.7 3.0 0.7 1.3 1.0 10.5 27.4 9.7 18.9 4.9 1,564 Control 62.8 50.3 12.8 0.7 33.2 0.3 0.6 0.4 16.1 4.2 0.1 0.6 1.8 11.1 29.2 13.7 20.5 6.3 1,542 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CURRENTLY MARRIED WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Pilot 72.3 62.9 21.7 1.2 38.2 0.0 1.2 0.5 26.1 3.7 0.9 1.7 1.1 12.7 33.1 11.2 23.0 6.1 1,146 Control 69.5 55.2 13.5 0.9 38.1 0.3 0.7 0.4 17.0 4.8 0.2 0.6 1.6 12.6 33.2 15.4 23.5 7.3 1,201 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– SEXUALLY ACTIVE UNMARRIED WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Pilot 55.3 48.7 9.2 1.3 17.1 1.3 1.3 0.0 34.2 1.3 1.3 0.0 0.0 5.3 11.8 2.6 7.9 2.6 76 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 25-49 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 ried women and 34 percent for sexually active unmarried women; in the control districts, condom use is 17 percent for married women and 23 percent for unmarried women.

Reported ever use of the pill in the pilot districts ranges from 9 percent among sexually active unmarried women to 22 percent among married women. In the control districts, 20 percent of unmarried women, 14 percent of married women, and 13 percent of all women have used the pill at some time.

Ever use of any traditional method was 33 percent for married women in both the pilot and the control districts.

3.3 Current Use of Contraceptive Methods

The contraceptive prevalence rate (CPR) is the most widely used measure of contraceptive use and is a reliable indicator of the success of family planning programmes. The CPR is defined here as the percentage of currently married women aged 15-49 who are using a modern method of contraception at the time of the survey. The use of currently married women (and not all women) as a base for the contraceptive prevalence rate is important when the CPR, as a single measure, is used for programme evaluation (i.e., trend assessment). This is because changing contraceptive use patterns combined with changing age patterns in marriage can complicate evaluation of an “all women” CPR over time.

Table 3.4 shows that the CPR (any modern method) for currently married women is 36 percent in the pilot districts and 30 percent in the control districts, a 6 percentage point advantage for the pilot districts. If all methods (including traditional methods) are considered, the CPR jumps to 41 percent in the pilot and 40 percent in the control districts. Use of traditional methods is 6 percent in the pilot districts and 10 percent in the control districts. The most commonly used traditional method is withdrawal, and the highest levels of withdrawal occur in Chitipa and Karonga districts in the Northern Region.

Looking at use of specific modern methods among married women, injectables are by far the most commonly used method: 18 percent of currently married women in the pilot and 19 percent in the control districts use this method. In the pilot districts, injectables are followed by male condoms (7 percent), the pill (6 percent), and female sterilisation (4 percent). In the control districts, pill use is lower (2 percent), as is condom use (4 percent), and female sterilisation is slightly higher (5 percent). All other modern methods are used by very few women in both the pilot and the control districts.

In the pilot districts, the CPR (modern methods) for unmarried sexually active women is 29 percent, which is lower than it is for currently married women (36 percent). However, in the control districts both sexually active unmarried women and married women have the same reported CPR, 30 percent. The male condom is the only method that is used by a greater proportion of unmarried women than married women. Presumably, this is related to the need felt by unmarried women for a temporary method that protects against both pregnancy and disease transmission. Again, the numbers of unmarried, sexually active women are small.

Table 3.4 indicates there is substantial variation among the 6 districts in the level of contraceptive use and method mix. The CPR (modern methods, currently married women) ranges from 23 percent in Karonga to 39 percent in Chitipa. The CPR for all methods is highest in Chitipa and Karonga, partly because of the relatively high prevalence of withdrawal as a method of family planning. Condom use is also much higher in Chitipa and Karonga than in other districts.

For currently married women, all of the pilot districts had higher prevalence of use of modern methods than their paired control districts with the exception of Ntchisi where the rate was lower than in Dowa. This discrepancy may be due in part to the presence in Dowa of a large, non-governmental family planning clinic, whereas there is no equivalent organisation in Ntchisi District.

17 Table 3.4 Current use of contraception

Percent distribution of all women, currently married women, and sexually active unmarried women who are currently using a contraceptive method, according to district and residence (pilot or control district), Malawi 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Modern method Traditional method –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––– Using Any any Any Female Male tradi- Periodic Number District/ meth- modern Inject- Foam/ Con- sterili- sterili- Im- tional absti- With- of residence od method Pill IUD able jelly dom sation sation plants LAM method nence drawal Other women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ALL WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– District Chitipa (P) 39.8 32.1 7.9 0.3 8.7 0.2 14.4 2.1 0.0 0.9 0.3 9.1 0.5 8.0 0.5 585 Karonga (C) 37.8 21.0 2.8 0.0 8.1 0.0 6.3 4.2 0.0 0.0 0.6 17.2 1.3 14.2 3.3 542 Ntchisi (P) 30.6 27.5 2.5 0.4 15.3 0.0 3.8 4.2 0.2 1.7 0.9 2.1 0.9 0.0 1.1 530 Dowa (C) 32.5 28.5 1.3 0.0 22.1 0.0 1.5 3.9 0.0 0.0 0.8 3.6 1.5 0.2 2.1 533 Chiradzulu (P) 32.6 30.8 4.0 0.4 21.6 0.2 2.8 2.6 0.0 0.2 0.4 1.4 0.4 0.8 0.4 500 Mulanje (C) 31.5 28.6 3.1 0.2 18.4 0.2 2.7 4.1 0.0 0.2 0.6 2.9 1.2 1.0 1.0 517

Residence Pilot 34.6 30.2 4.9 0.4 14.9 0.1 7.3 2.9 0.1 0.9 0.6 4.4 0.6 3.2 0.7 1,615 Control 34.0 26.0 2.4 0.1 16.1 0.1 3.5 4.1 0.0 0.1 0.6 8.0 1.3 5.2 2.1 1,592 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CURRENTLY MARRIED WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– District Chitipa (P) 48.3 38.5 10.0 0.5 10.8 0.2 15.6 2.9 0.0 1.2 0.5 11.7 0.5 10.8 0.5 418 Karonga (C) 42.7 22.7 2.1 0.0 9.4 0.0 7.1 4.6 0.0 0.0 0.7 20.4 1.6 17.0 3.9 436 Ntchisi (P) 35.8 32.6 2.9 0.5 19.0 0.0 3.2 5.1 0.2 2.2 0.7 2.4 1.0 0.0 1.5 411 Dowa (C) 40.3 35.4 1.5 0.0 27.5 0.0 1.5 5.2 0.0 0.0 1.0 4.5 1.7 0.2 2.7 404 Chiradzulu (P) 38.3 35.7 4.4 0.6 26.3 0.3 2.7 2.7 0.0 0.0 0.6 2.1 0.6 1.2 0.6 339 Mulanje (C) 35.2 31.8 2.9 0.3 20.8 0.3 3.1 4.4 0.0 0.3 0.5 3.4 1.6 1.0 1.0 384

Residence Pilot 41.0 35.6 5.9 0.5 18.2 0.2 7.4 3.6 0.1 1.2 0.6 5.7 0.7 4.2 0.9 1,168 Control 39.5 29.7 2.1 0.1 19.0 0.1 4.0 4.7 0.0 0.1 0.7 9.8 1.6 6.5 2.6 1,224 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– SEXUALLY ACTIVE UNMARRIED WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Pilot 32.9 29.1 1.3 0.0 7.6 0.0 19.0 1.3 0.0 0.0 1.3 2.5 1.3 1.3 0.0 79 Control (30.0) (30.0) (10.0) (0.0) (13.3) (0.0) (6.7) (3.3) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) 30 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Figures in parentheses are based on 25-49 cases. LAM = Lactational amenorrhea method

In Table 3.4, for the category of sexually active unmarried women there were fewer than 50 respondents in each district, so the CPR was not reported by district.

Figure 3.2 shows changes in current contraceptive use between the 1999 and 2003 surveys. The CPR for any modern method increased by 12 percentage points in the PopFP pilot districts compared with an increase of only 5 percentage points in the control areas. While use of traditional methods remained the same in the control districts, it decreased from 9 percent to 6 percent in the pilot project districts. Changes in contraceptive prevalence for specific modern methods were not large but, with the exception of the pill and male condoms in the control districts, were in a positive direction.

18 Figure 3.2 Percentage of Currently Married Women Using Contraceptive Methods by Residence (Pilot or Control District)

36 30 Any modern method 24 25 6 10 Any traditional method 9 10 18 19 Pilot '03 Injectables 14 14 Control '03 6 Pilot '99 2 Pill 4 Control '99 2 7 4 Male condom 4 5 4 5 Female sterilisation 3 4 0 10203040

Percent

3.4 Number of Children at First Use of Contraception

Family planning can be used to limit family size or for spacing or delaying births. Couples who want large families will tend not to use contraception until late in their reproductive lives, at which time they may decide to use it to stop any additional childbearing. On the other hand, couples who use contraception to increase the length of birth intervals will tend to begin using contraception earlier for purposes of delaying pregnancy. To obtain information on the relationship between first use of contraception and number of children, the FPRHS asked women how many children they had when they first used family planning.

Table 3.5 shows the distribution of ever-married women by number of children at the time of first use of contraception and residence (pilot or control district), according to age. Younger cohorts of women reported first use at lower parity than older cohorts of women. For example, in the pilot districts, about 21 percent of women age 15-19, 7 percent of women aged 20-24 and 2 percent or less of women age 25 and older used a contraceptive method before having a child. A similar though slightly less pronounced pattern is observed in the control districts. This finding is consistent with an increasing tendency among women to adopt contraception for child-spacing purposes (i.e., at younger ages).

A comparison of the FPRHS99 and FPRHS03 surveys reveals that the tendency for women to use contraception before having a child has become more prevalent at younger ages, especially in the pilot districts. As Figure 3.3 shows, in 2003 in the pilot districts, 21 percent of women aged 15-19, and 7 percent aged 20-24 used contraception before their first child, while, in 1999, only 11 percent of the 15-19 age group and 6 percent of those 20-24 did so. In the control districts, the increasing prevalence of contraceptive use among the youngest age groups is also evident, but less so, particularly at the youngest ages: in 2003, 13 percent of women aged 15-19 and 6 percent of those 20-24 used contraception at zero parity, while, in 1999, 10 percent of women aged 15-19 and 4 percent of those 20-24 did so in the control districts. The most striking move toward contraceptive use at zero parity is among women aged 15-19 in the PopFP pilot areas.

19 Table 3.5 Number of children at first use of contraception for ever-married women

Percent distribution of ever-married women by number of living children at the time of first use of contraception and residence (pilot or control district), and median number of children at first use, according to current age, Malawi 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Median Never number used Number of living children at time of first use of contraception of children Number contra- –––––––––––––––––––––––––––––––––––––––––––––––––––––– at first use of of Age ception 0 1 2 3 4+ Missing Total contraception women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– PILOT DISTRICTS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 51.9 20.9 25.3 1.9 0.0 0.0 0.0 100.0 1.0 158 20-24 32.0 7.2 44.2 12.7 2.5 1.4 0.0 100.0 1.0 362 25-29 21.1 2.4 32.3 28.3 10.4 5.6 0.0 100.0 2.0 251 30-34 25.0 1.8 17.7 21.8 16.4 16.4 0.9 100.0 2.0 220 35-39 23.9 1.1 13.6 8.5 11.4 41.5 0.0 100.0 4.0 176 40-44 29.6 2.2 11.1 11.9 11.9 33.3 0.0 100.0 3.0 135 45-49 34.6 0.0 7.4 8.6 9.9 37.0 2.5 100.0 4.0 81 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CONTROL DISTRICTS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15-19 60.2 12.6 25.1 2.1 0.0 0.0 0.0 100.0 1.0 191 20-24 32.5 5.6 41.9 14.7 3.9 0.8 0.6 100.0 1.0 360 25-29 20.6 1.4 33.8 24.7 11.5 8.0 0.0 100.0 2.0 287 30-34 25.5 0.0 20.0 21.8 13.2 19.1 0.5 100.0 2.0 220 35-39 30.3 0.0 16.0 11.4 6.3 35.4 0.6 100.0 4.0 175 40-44 31.4 1.7 9.1 12.4 11.6 33.9 0.0 100.0 3.0 121 45-49 51.4 0.0 6.9 5.6 0.0 36.1 0.0 100.0 4.0 72

Figure 3.3 Use of Modern Contraceptive Methods Before the Birth of the First Child by Residence (Pilot or Control District) and Age Group (15-19 and 20-24)

13 FPRHS03 7

6 Pilot age 15-19 Control age 15-19 Pilot age 20-24 11 Control age 20-24

10 FPRHS99 6

0 5 10 15 20 25

Percent

3.5 Source of Family Planning Methods

Table 3.6 shows the proportion of respondents who reported obtaining specific modern methods of contraception from various sources. The majority of respondents obtained their last modern contraceptive method from government (public) institutions (89 percent of users in the pilot districts, 75 percent in the

20 Table 3.6 Source of supply among current users

Percent distribution of current users of modern contraceptive methods by most recent source of supply, according to method and residence (pilot or control district), Malawi 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Male Female All modern Source of supply Pill Injectables condom sterilisation methods ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– PILOT DISTRICTS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Public sector 96.2 89.2 93.2 (66.0) 88.5 Government hospital 6.3 25.0 9.4 (63.8) 24.5 Government health centre 25.3 58.8 15.4 (2.1) 35.2 Dispensary/maternity clinic 0.0 0.4 4.3 (0.0) 1.2 Mobile clinic 1.3 4.2 2.6 (0.0) 2.8 CBDA 63.3 0.8 60.7 (0.0) 23.9 Other public 0.0 0.0 0.9 (0.0) 0.8

Private medical sector 1.3 10.8 2.6 (27.7) 8.7 Private hospital 0.0 0.8 0.0 (8.5) 1.2 Private health centre 1.3 9.6 2.6 (8.5) 6.0 Dispensary/maternity clinic 0.0 0.4 0.0 (2.1) 0.6 Other private medical 0.0 0.0 0.0 (8.5) 0.8

Other private source 0.0 0.0 4.3 (0.0) 1.4 Shop/pharmacy 0.0 0.0 2.6 (0.0) 0.6 Friend/relative 0.0 0.0 1.7 (0.0) 0.8

Other 0.0 0.0 0.0 (0.0) 0.2 Missing 2.5 0.0 0.0 (6.4) 1.2

Total 100.0 100.0 100.0 100.0 100.0 Number 79 240 117 47 497 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CONTROL DISTRICTS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Public sector (92.1) 87.5 60.7 32.3 74.6 Government hospital (23.7) 19.8 14.3 30.8 20.6 Government health centre (47.4) 61.5 35.7 1.5 46.4 Dispensary/maternity clinic (2.6) 3.5 1.8 0.0 2.6 Mobile clinic (2.6) 1.9 3.6 0.0 2.1 CBDA (15.8) 0.4 3.6 0.0 2.1 Other public (0.0) 0.4 1.8 0.0 0.7

Private medical sector (2.6) 11.3 3.6 58.5 17.1 Private hospital (2.6) 5.8 0.0 27.7 8.5 Private health centre (0.0) 1.2 0.0 4.6 1.4 Dispensary/maternity clinic (0.0) 3.9 1.8 0.0 2.6 Private doctor (0.0) 0.0 0.0 1.5 0.2 Other private medical (0.0) 0.4 1.8 24.6 4.3

Other private source (0.0) 0.0 33.9 0.0 4.7 Shop/pharmacy (0.0) 0.0 33.9 0.0 4.5 Friend/relative (0.0) 0.0 0.0 0.0 0.2

Other (0.0) 0.4 0.0 4.6 1.4 Don’t know (0.0) 0.0 0.0 1.5 0.2 Missing (5.3) 0.8 1.8 3.1 1.9

Total 100.0 100.0 100.0 100.0 100.0 Number 38 257 56 65 422 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Note: Figures in parentheses are based on 25-49 cases.

21 control districts). Government health centres are the most commonly used single source of modern contraceptive methods, accounting for almost half of reported sources in the control districts and more than a third in the pilot districts. Private medical sources accounted for 9 percent of use of modern methods in the pilot districts and 17 percent in the control districts. Reliance on public sector sources for modern contraceptive methods thus appears to be greater in the pilot districts than in the control districts, possibly due to the activities in the pilot districts of CBDAs trained by PopFP.

In the pilot districts, 24 percent of respondents reported obtaining their last modern contraceptive method from a CBDA, while in the control districts the CBDAs supplied only 2 percent of modern methods. CBDAs play a major role in supplying contraceptives to women in the pilot districts and a contrasting negligible role in the control areas. This finding underscores the possible success of the PopFP project in strengthening the role of the CBDA in implementation districts.

Figure 3.4 compares the percentages of all current users of modern contraceptive methods who obtained their current method from various sources at the time of the baseline survey in 1999 and the follow-up survey in 2003. In the pilot areas, government health centres declined as a source of supply between the two surveys: in 1999, 47 percent of users of modern methods reported having obtained modern contraceptives from government health centres compared with only 35 percent of users in 2003. In the control areas, the proportion of women reporting that their current modern method came from a government health centres remained virtually the same in 2003 compared with 1999. In both the pilot and control areas, the proportion of respondents reporting government hospitals as a source of supply also remained unchanged between 1999 and 2003.

Figure 3.4 Source of Supply for Current Users of Modern Contraceptive Methods by Residence (Pilot or Control District)

35 Government 46 Health Centre 47 47 25 Government 21 Hospital 26 21 Pilot '03 2 Public Mobile 2 Control '03 Unit 7 Pilot '99 3 Control '99 24 Community Based 2 Distribution Agents 1 1 9 Private 17 Facilities 13 20 0 1020304050

Percent

Private facilities and public mobile clinics declined as sources, as fewer women reported obtaining family planning methods from them in 2003 compared with 1999. In the pilot districts these declines were ac- companied by a large increase in the percentage of women stating that they obtained their current modern method from CBDAs. As noted above, promotion of CBDAs as a source of family planning was a major strategy of the PopFP Project.

3.6 Contact of Nonusers of Family Planning with Family Planning Providers

In the FPRHS03 women were asked whether they had been visited by a family planning fieldworker in the 12 months prior to the interview. They were also asked if they had visited a health centre during the previous 12 months. Respondents who had visited a health centre were asked whether staff at the centre had discussed family planning methods with them. This information is important for the PopFP project, which aimed to increase the prevalence of contacts between CBDAs and other family planning workers and women aged 15-49, especially those who did not use contraception. Another goal of the project was to train staff in health centres to give family planning advice to all women aged 15-49, especially nonusers of family planning.

Table 3.7 shows that the prevalence of contacts by nonusers with family planning providers was much higher in the pilot districts compared with the control districts. In the control districts, 71 percent of nonusers of family planning claimed that they had not been visited by a family planning fieldworker and had not received family planning counselling from the staff of a health facility, compared with 58 percent in the pilot districts.

The percentage of women contacted in their community by a family planning fieldworker can be obtained by summing the first three columns of Table 3.7. This shows that 27 percent of nonusers in the pilot districts had received a visit by a family planning worker compared with only 9 percent of nonusers in the control districts.

In the pilot districts, 30 percent of the nonusers reported that, although they were not visited by a family planning fieldworker, they did attend a health facility, but did not have an opportunity to discuss family planning during the visit to the health facility. For the control districts, the comparable figure is 34 percent. These cases may be viewed as “missed opportunities” because, although the women did not have contact with a family planning fieldworker, they could have been given family planning advice when they attended a health facility. However, they reported during the survey interview that no staff member spoke to them about family planning when they visited a facility.

The probability of being exposed to family planning information is related to age. Table 3.7 shows that for both the pilot and control districts the youngest nonusers are least likely to have received counseling. Women in their peak childbearing years or just after are most likely to have received family planning advice. In both the pilot and control districts, women aged 15-19 appear to be disadvantaged relative to older women in terms opportunities to discuss family planning. This disadvantage is more marked in the control districts.

Table 3.7 also reveals some association between educational level and the likelihood that a woman not using contraception will receive visits from fieldworkers and family planning advice at clinics. In the control areas, women with no education are less likely to receive the optimum level of family planning advice which consists of a visit by a fieldworker and counseling at a clinic. In the pilot areas, this pattern does not exist.

23 Table 3.7 Contact of nonusers with family planning providers

Percent distribution of women who were not using contraception by whether or not they were visited by a family planning field worker or spoke with a health facility staff member about family planning during the 12 months prior to the interview, according to background characteristics and residence (pilot or control district), Malawi 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Visited by family Not visited by family planning fieldworker planning fieldworker ––––––––––––––––––––––– ––––––––––––––––––––––– Attended Attended Attended facility Attended facility Neither visited facility but facility but by family planning and did not and did not worker nor discussed discuss Did not discussed discuss Did not discussed family Number Background family family attend family family attend planning at of characteristic planning planning facility planning planning facility Missing health facility Total women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– PILOT DISTRICTS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 6.6 5.0 9.3 9.3 30.1 39.4 0.4 69.5 100.0 259 20-24 11.8 7.2 7.2 15.8 37.6 19.9 0.5 57.5 100.0 221 25-29 14.3 10.7 3.6 19.6 27.7 24.1 0.0 51.8 100.0 112 30-34 16.7 11.8 5.9 14.7 32.4 18.6 0.0 51.0 100.0 102 35-39 14.1 5.9 7.1 23.5 27.1 22.4 0.0 49.4 100.0 85 40-44 10.4 9.1 15.6 15.6 27.3 20.8 1.3 48.1 100.0 77 45-49 13.6 3.4 11.9 20.3 15.3 35.6 0.0 50.8 100.0 59

Education No education 8.9 8.3 7.8 14.4 26.1 33.3 1.1 59.4 100.0 180 Primary 12.0 6.8 9.0 16.5 30.4 25.2 0.2 55.6 100.0 619 Secondary 12.1 8.6 4.3 10.3 37.1 27.6 0.0 64.7 100.0 116

Total 11.4 7.3 8.2 15.3 30.4 27.1 0.3 57.5 100.0 915 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CONTROL DISTRICTS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 1.8 1.1 1.8 13.4 28.6 53.3 0.0 81.9 100.0 276 20-24 5.4 2.0 0.5 26.5 37.3 28.4 0.0 65.7 100.0 204 25-29 6.9 3.1 2.3 29.0 33.6 23.7 1.5 57.3 100.0 131 30-34 8.4 1.9 1.9 24.3 33.6 29.9 0.0 63.6 100.0 107 35-39 4.4 6.6 2.2 19.8 34.1 33.0 0.0 67.0 100.0 91 40-44 1.4 1.4 1.4 17.6 43.2 33.8 1.4 77.0 100.0 74 45-49 6.0 10.0 0.0 10.0 40.0 34.0 0.0 74.0 100.0 50

Education No education 1.8 4.1 1.4 17.1 33.6 41.5 0.5 75.1 100.0 217 Primary 5.2 2.4 1.8 21.2 32.7 36.3 0.3 69.1 100.0 614 Secondary 5.9 1.0 0.0 23.5 43.1 26.5 0.0 69.6 100.0 102

Total 4.5 2.7 1.5 20.5 34.1 36.4 0.3 70.5 100.0 933

Figure 3.5 illustrates changes in access to family planning advice for nonusers of contraceptives between the FPRHS99 and FPRHS03 surveys. The proportion of nonusers who said they had not been visited by a family planning fieldworker and had not received family planning counselling from the staff of a health facility declined by 13 percentage points from 67 percent in 1999 to 58 percent in 2003 in districts in which the pilot PopFP interventions were delivered. However, the comparable percentage in the control districts actually increased by 4 percentage points from 67 percent in 1999 to 71 percent in 2003. An even sharper contrast between the pilot and control areas in 1999 and 2003 is shown in Figure 3.4 with regard to nonusers reporting visits by family planning fieldworkers: while the prevalence of reported visits increased in the PopFP programme districts from 17 percent to 27 percent, prevalence decreased in the control areas from 19 to 9 percent.

24 Figure 3.5 Contact of Nonusers of Contraceptive Methods With Family Planning Providers by Residence (Pilot or Control District)

58 Not Visited by FP Worker and Not 71 Counseled at 67 FacilityFaci 67

27 Pilot '03 Visited by 9 Control '03 FP Worker 17 Pilot '99 Control '99 19

30 Not Visited by FP Not Visited by FP 34 WorkerWorker andand VisitedVisited Facility Facilitybut FP Notbut 20 Discussed 23

0 20406080 Percent

In connection with Table 3.7, it was noted that nonusers who were not visited by a family planning worker but did visit a health facility where staff did not give them family planning advice constitute a “lost opportunity” for counseling. A look at Figure 3.5 reveals that the reported prevalence of “lost opportunity” clients actually increased by 10 percentage points in the PopFP pilot districts from 1999 to 2003. In the control areas lost opportunities for counseling increased by a similar amount, 11 percentage points. It is possible that institutional factors outside the sphere of PopFP activities led to this decline in counseling in facilities in both the pilot and control districts.

3.7 Attitudes of Women Toward Family Planning

FPRHS03 respondents were asked if they approved of family planning. Table 3.8 shows the responses of women who were currently married and who knew at least one method of family planning. In the pilot districts, 95 percent of women reported that they approve of family planning, while, in the control areas, 92 percent expressed approval. Amongst individual districts, percentages expressing approval vary slightly between 94 and 96 percent, with the exception of Karonga, where approval is lower at 86 percent. In the pilot districts as a group, there is little variation by education. In the control districts, however, the association with education is stronger: approval increases from 88 percent for women with no formal education to 97 percent for women with secondary schooling. In terms of age, there is slightly higher prevalence of approval among women in the childbearing years, especially in the control districts. Over- all, there is more variation in levels of approval by education and age in the control districts than there is in the pilot districts. In the PopFP project areas, women appear more consistent in approval of family planning.

As reported by FPRHS99, approval of family planning was already widespread in both the pilot and control districts in 1999: 89 percent of respondents in both areas reported approval of family planning. Be- tween 1999 and 2003, in the pilot districts approval increased from 89 to 95 percent, while in the control areas approval increased from 89 to 92 percent.

Table 3.8 Approval of family planning

Percentage of currently married women who know at least one contraceptive method and who approve of family planning by age, education, district, and residence (pilot or control district), Ma- lawi 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– District ––––––––––––––––––––––––––––––––––––––––––––––––––– Residence Chirad- ––––––––––––––– Background Chitipa Karonga Ntchisi Dowa zulu Mulanje Pilot Control characteristic (P) (C) (P) (C) (P) (C) districts districts ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 84.4 76.4 96.2 92.6 93.0 91.8 90.4 86.0 20-24 93.2 86.5 95.5 91.0 93.9 99.0 94.2 92.1 25-29 98.7 93.5 97.2 95.3 94.4 96.1 96.8 94.9 30-34 95.0 83.3 92.8 100.0 98.1 91.3 95.1 90.3 35-39 96.9 89.5 98.3 100.0 93.3 94.5 96.8 95.2 40-44 89.2 78.1 100.0 97.3 96.3 91.3 95.2 89.1 45-49 100.0 87.5 95.8 85.0 93.3 85.0 96.7 85.7

Education No education 91.3 67.3 95.6 92.8 90.8 92.3 93.2 88.1 Primary 94.7 87.6 96.2 95.7 96.1 95.2 95.6 92.2 Secondary 92.7 94.3 100.0 100.0 93.9 96.6 94.7 96.5

Total 94.1 85.7 96.3 94.9 94.7 94.5 95.0 91.5 Number 409 420400 392 337 3821,146 1,201

26 CHAPTER 4

FERTILITY PREFERENCES

In the FPRHS03, women were asked about their preferences concerning having a child in the future and the length of time before having a child. Women who stated a preference for not having a child and who were not using contraception were asked why they were not using a family planning method.

The interpretation of survey data on fertility preferences is often difficult, since it is understood that respondents’ reported preferences are, in a sense, hypothetical and thus subject to change and rationalisa- tion. Still, the utility of information on the desire for children to anticipate changes in actual fertility behaviour (i.e., adoption of contraception) has been demonstrated in a wide variety of contexts.

4.1 Fertility Preferences of Currently Married Women by Number of Living Children

Women who were not sterilised were asked if they would like to have a child or, if they had already given birth, whether they would like to have another child. If they stated that they would like to give birth, they were then asked how long they would like to wait before doing so. Table 4.1 presents fertility desires of respondents according to number of living children and residence (pilot or control district).

Table 4.1 Fertility preferences of currently married women by number of living children

Percentage distribution of currently married women by desire for children, according to number of living children and residence (pilot or control district), Malawi 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of living children Desire –––––––––––––––––––––––––––––––––––––––––––––––––––––––– for children 0 1 2 3 4 5 6+ Total –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– PILOT DISTRICTS –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Future intentions Have another soon1 31.0 15.5 8.7 5.4 4.2 7.0 3.0 9.3 Have another later2 49.0 62.4 61.6 49.1 34.7 18.3 8.6 40.8 Have another later, undecided when 3.0 2.2 0.0 3.6 0.7 1.7 0.0 1.4 Want no more 5.0 12.2 17.9 28.7 45.1 54.8 66.4 34.1 Sterilised 0.0 0.0 1.3 3.0 4.9 3.5 9.9 3.6 Declared infecund 3.0 3.3 5.7 3.0 3.5 7.8 7.3 5.0 Missing 9.0 4.4 4.8 7.2 6.9 7.0 4.7 5.9

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 100 181 229 167 144 115 232 1,168 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CONTROL DISTRICTS –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Future intentions Have another soon1 46.5 20.5 11.7 5.3 8.8 4.7 1.9 13.0 Have another later2 35.4 65.1 62.3 56.1 42.9 26.8 7.7 43.7 Have another later, undecided when 2.4 1.5 1.3 1.1 0.7 0.0 0.5 1.1 Want no more 6.3 8.7 18.6 26.5 39.5 56.7 66.8 31.6 Sterilised 0.0 1.5 1.3 5.3 4.1 3.1 15.4 4.7 Declared infecund 3.1 1.5 1.7 2.6 0.0 3.1 2.9 2.1 Missing 6.3 1.0 3.0 3.2 4.1 5.5 4.8 3.8

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 127 195 231 189 147 127 208 1,224 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Within the next two years 2 After two years

27 Fifty-two percent of all married women in the pilot districts and 58 percent in the control districts reported that they wanted to have another child. However, only 9 percent of these respondents in the pilot districts and 13 percent in the control districts stated that they would like to have one soon (in the next two years), while 41 percent of respondents in the pilot districts and 44 percent in the control districts expressed a desire to have another child after a delay of two years. An additional 1 percent of respondents in both the pilot and control areas stated that they wanted to have another child but were undecided as to when they would give birth again. Thirty-four percent of women in the pilot districts and 32 percent in the control districts stated that they wanted no more children. This means that 76 percent of currently married women in both the pilot and control districts would like either to delay or to prevent a pregnancy, and are currently in need of either a temporary or a permanent means of fertility control.

As expected, in both the pilot and the control districts, the desire to space the birth of a child (have another later) declines with increasing number living children. On the other hand, the expressed desire to limit childbearing (cease childbearing) increases sharply with the number of living children. The net ef- fect of these two patterns is that, once childbearing begins, the proportion of women falling into one of the two groups (spacers or limiters) is roughly constant across parity at 75 to 81 percent in the pilot districts and 75 to 84 percent in the control districts.

Figure 4.1 shows changes in fertility preferences between the baseline 1999 survey and the end-of-project survey carried out in 2003. The percentage of respondents who declared that they wished to have no more children increased by the same small percentage in the pilot and control districts (3 percentage points). The proportion of respondents who expressed a desire to space children (have another after two years) decreased slightly in both the pilot and control districts (4 percentage points in the pilot areas and 1 percentage point in the control areas). Among respondents in both groups, the percentages who stated a wish to have another child soon remained almost constant between 1999 and 2003: 10 percent of the pilot respondents reported that they wished to have another child soon in 1999 compared with 9 percent in 2003, while the percentage of the control respondents who expressed this wish was 15 percent in 1999 and 13 percent in 2003. Thus, with regard to an expressed desire for family limitation and for child spacing, there is some evidence of an increase in attitudes favouring family planning but the differences between the pilot and control districts are small.

Figure 4.1 Percent Distribution of Currently Married Women Age 15-49 by Desire for More Children and Residence (Pilot or Control District)

34 32 Want No More 31 29 41 Have Another Later 44 (After 2 Years) 45 45 Pilot '03 9 13 Control '03 Have Another Soon 10 Pilot '99 15 Control '99 4 5 Sterilised 3 5 5 2 Infecund 7 4 0 1020304050

Percent

28 CHAPTER 5

AIDS KNOWLEDGE AND PREVENTION

Acquired immune deficiency syndrome (AIDS) is recognised as an important public health problem in Malawi. Accordingly, prevention campaigns for AIDS have been launched throughout the nation by MOHP through the National AIDS Commission (NAC). The Ministry of Education and Culture, the Min- istry of Women and Children’s Affairs, and various non-governmental organisations (NGOs) are also im- plementing AIDS programmes. Condoms are being made available by various agencies in Malawi by means of free distribution and social marketing.

AIDS information, education, and communication (IEC) programs were part of the PopFP Project’s strategy. CBDAs were trained to provide information about prevention of AIDS. Young people were also trained as peer educators to promote healthy life skills through peer education. Peer educators stressed use of condoms and sexual abstinence before marriage and distributed free condoms to young people. PopFP also trained personnel in health facilities to provide preventive counselling to clients.

5.1 Knowledge of HIV/AIDS

The FPRHS03 asked respondents if they had ever heard of a virus called HIV or an illness called AIDS. The findings on general knowledge of HIV/AIDS are given in Table 5.1. The prevalence of AIDS knowledge is 98 percent for women in the pilot districts and 99 percent in the control districts. These figures are very similar to those reported in the FPRHS99, in which 98 percent of women in both the pilot and control areas reported having heard of AIDS. Knowledge of AIDS is virtually universal in Malawi among women aged 15-49.

Table 5.1 General knowledge of HIV/AIDS

Percentage of women who know of HIV/AIDS by background characteristics and residence (pilot or control district), Malawi 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Pilot districts Control districts ––––––––––––––––––––– –––––––––––––––––––– Background Knows of Number Knows of Number characteristic HIV/AIDS of women HIV/AIDS of women –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 97.9 331 97.6 327 20-24 98.8 403 98.4 383 25-29 98.5 259 99.3 290 30-34 98.7 223 98.2 221 35-39 98.9 180 100.0 178 40-44 95.6 135 99.2 121 45-49 97.6 84 95.8 72

Marital status Currently in union 98.6 1,168 98.4 1,224 Formerly in union 98.1 215 98.5 202 Never married 96.1 232 98.8 166

Education No education 95.3 297 96.9 350 Primary 98.7 1,128 98.8 1,096 Secondary 100.0 190 100.0 146

All women 98.2 1,615 98.5 1,592

Knowledge of AIDS increases with educa- Table 5.2 Knowledge of ways to avoid HIV/AIDS tion. In the pilot districts, 95 percent of women with no education have some Among women who reported knowing a way to avoid HIV/AIDS, knowledge compared with 99 percent or the percentage knowing specific ways, by residence (pilot or control more of women who have primary or districts), Malawi 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––– secondary education. Similar variations in Residence knowledge of AIDS by educational level –––––––––––––––––––– were reported in the control districts, Pilot Control Question/response districts districts where 97 percent of women with no edu- ––––––––––––––––––––––––––––––––––––––––––––––––––––––––– cation reported having some familiarity Can AIDS be avoided? with AIDS compared with over 99 percent Yes 95.5 91.8 of respondents with primary or secondary No 2.3 4.7 Don't know 2.1 3.4 schooling. In 1999, knowledge of AIDS Missing 0.1 0.1 varied from 96 percent for women with no education to more than 98 percent for Number of respondents 1,586 1,568 those with some schooling. Knowledge of Ways to avoid AIDS AIDS has been widespread in both the Abstain from sex 97.0 95.3 pilot and control districts for the past three Use condoms 90.1 85.7 years. Limit sex to one partner/stay faithful to one partner 89.0 90.1 Limit number of sexual partners 1.5 3.5 5.2 Knowledge of Ways to Avoid Avoid sex with prostitutes 12.8 10.9 HIV/AIDS Avoid sex with persons who have many partners 8.2 9.4 Avoid sex with homosexuals 0.5 0.6 Respondents were asked if AIDS can be Avoid sex with persons who avoided and most answered correctly that inject drugs intravenously 1.3 1.0 prevention is possible. As seen in Table Avoid blood transfusions 4.8 5.5 Avoid injections 11.3 10.2 5.2, 96 percent of women in the pilot Avoid kissing 1.4 1.4 districts and 92 percent in the control Avoid mosquito bites 24.2 31.9 districts reported that AIDS can be Seek protection from a prevented. Respondents were asked to traditional healer 2.3 0.7 Avoid sharing razors/blades 29.5 23.0 name specific ways to avoid getting the Do not share food with someone disease. The most commonly mentioned who has AIDS 14.1 23.0 way to avoid AIDS was abstaining from Other 0.9 0.4 sex, cited by 97 percent of respondents in Does not know of specific ways 0.1 0.1 the pilot districts and by 95 percent in the Number of women 1,514 1,440 control districts. Eighty-nine percent of respondents in the pilot districts and 90 percent in the control districts mentioned limiting sex to one faithful partner. Ninety percent of respondents in the pilot districts and 86 percent in the control districts cited using condoms as a method of prevention.

5.3 Knowledge of Programmatically Important Ways to Avoid AIDS

In preventing transmission of the AIDS virus, some methods are more important or effective as public health measures than others. Table 5.3 gives the proportion of respondents who mentioned spontaneously, or affirmed when prompted, one or more of the following ways to avoid HIV/AIDS: abstaining from sex, using condoms, limiting sex to one partner, and limiting the number partners. Table 5.3 shows that 18 percent of respondents in the pilot districts and 20 percent in the control districts knew only two of these ways to avoid HIV/AIDS, while 74 percent in the pilot districts and 68 percent in the control districts knew three or more ways.

30 Studies in several African countries have shown that prompted questions on ways to avoid AIDS can clar- ify in a respondent’s mind her knowledge and beliefs concerning the effectiveness of various methods for avoiding HIV/AIDS. Table 5.3 shows the proportion of respondents who cited “condoms” “limiting sex partners,” and “abstaining from sex” as ways to avoid AIDS, when specifically asked about the effectiveness of these methods. Eighty-three percent of women in the pilot districts and 79 percent of women in the control districts replied in the affirmative when asked whether condoms could protect against transmission of the AIDS virus. Even larger proportions of respondents cited limiting the number of sex partners as being effective. Ninety-eight percent of respondents in the pilot districts and 99 percent in the control districts affirmed the effectiveness of partner limitation when asked about it. Finally, 89 percent of respondents in the pilot areas and 90 percent in the control districts agreed that abstaining from sex was a means to avoid infection. In general, knowledge of valid ways to avoid AIDS is very high in the PopFP study area.

Table 5.3 Knowledge of specific ways to avoid getting the AIDS virus

Percent distribution of women who were not using contraception by whether or not they were visited by a family planning field worker or spoke with a health facility staff member about family planning during the 12 months prior to the interview, according to background characteristics and residence (pilot or control district), Malawi 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Knowledge of programmatically important ways to avoid AIDS1 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Knowledge of specific ways Knows to avoid AIDS (prompted)2 AIDS, but –––––––––––––––––––––– Does cannot Knows Knows Have not name any one way Knows three only Abstain know means to to avoid two or more Use one sex from Residence AIDS avoid it AIDS ways ways Missing Total Number condoms partner sex –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Pilot districts 1.8 4.5 2.2 17.5 73.9 0.1 100.0 1,615 82.7 98.1 88.5 Control districts 1.5 8.0 2.7 19.7 68.0 0.1 100.0 1,592 79.4 98.7 90.0 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 Includes abstaining from sexual intercourse, using condoms, limiting the number of partners, and staying faithful to one partner or limiting sex to one partner 2 Respondents were "prompted" regarding use of condoms and limiting sex partners, by specifically asking them if these methods could protect a person from getting the AIDS virus.

Figure 5.1 compares the prevalence of knowledge of programmatically important ways to avoid HIV/AIDS as reported in FPRHS99 and FPRHS03 for the pilot and control districts. The percentage of respondents reporting knowledge of three or more ways to avoid HIV infection increased slightly in the pilot areas from 71 to 74 percent and declined slightly in the control areas from 71 to 68 percent. The percentages of respondents who know only one or two preventive methods have remained stable, with only small variations.

31 Figure 5.1 Percentage of Women Who Know of Programatically Important Ways to Avoid HIV/AIDS by Residence (Pilot or Control District)

74 Knows 3 or More 68 Ways to Avoid 71 HIV/AIDS 71

18 Knows Only 2 Ways 20 to Avoid HIV/AIDS 18 Pilot '03 18 Control '03 2 Pilot '99 Knows Only 1 Way 3 Control '99 to Avoid HIV/AIDS 3 2

6 Does Not Know AIDS 10 oror KnowsKnows AIDSAIDS ButBut 8 Not HowNot toHow Avoid to Av It 9

0 20406080

Percent

5.4 Knowledge of Issues Related to Transmission of the AIDS Virus

Table 5.4 shows the proportion of respondents who were aware of the fact that a healthy-looking person can harbour the HIV virus and that HIV can be transmitted from mother to child. Knowing that healthy looks can be deceiving may constrain people from having sexual intercourse with persons whose HIV status they do not actually know. Knowledge of mother to child transmission may persuade women to be more careful about avoiding the risk of infection, while those women who know that they have HIV may adopt effective measures to prevent pregnancy. Eighty-seven percent of women in both the pilot and control districts know that a healthy-looking person can have the AIDS virus. Eighty-eight percent of women in the pilot districts and 85 percent in the control districts are aware that a mother can transmit the AIDS virus to a newborn child.

Table 5.4 Percentage of women who know of HIV/AIDS by responses to questions on various AIDS-related issues by pilot and control districts

Percentage of women who know of HIV/AIDS by response to questions on various AIDS-related issues and residence (pilot or control district), Malawi 2003 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Do you know someone personally who has Can a healthy-looking Can the AIDS virus be the AIDS virus or who person have the AIDS virus? transmitted from mother to child? has died of AIDS? –––––––––––––––––––––––––––– –––––––––––––––––––––––––––––– –––––––––––––––––––––– Number Don’t Don’t of Residence Yes No know Missing Yes No know Missing Yes No Missing women ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Pilot districts 87.2 8.6 3.5 0.7 88.3 6.4 5.2 0.0 76.9 22.3 0.8 1,586 Control districts 86.5 9.1 4.1 0.3 85.1 9.8 5.0 0.1 76.1 22.8 1.0 1,568

32 Knowing someone who is infected with HIV or has died of AIDS may encourage risk avoidance. Sev- enty-seven percent of women in the pilot districts know someone with HIV or who has died of AIDS, compared with 76 percent in the control districts. The fact that around 3 in 4 women have personal ex- perience with AIDS victims emphasises the enormous social impact of the AIDS epidemic in Malawi.

Figure 5.2 compares the results of the FPRHS99 and FPRHS03 with regard to issues related to HIV/AIDS transmission. Overall, there has been little change in knowledge about HIV transmission. Knowledge that an apparently healthy person can have HIV remained essentially the same in the pilot and control areas between the two surveys. In the control districts, there has been a slight decline in awareness that HIV can be transmitted from mother to child (88 percent in 1999 to 85 percent in 2003). In the pilot districts, knowledge of mother-to-child transmission remained stable. The most notable change has been an increase in the percentage of respondents who know someone with HIV or someone who is dying of AIDS in the control districts(from 70 to 76 percent).

Figure 5.2 Percent Distribution of Currently Married Women Age 15-49 Who Have Knowledge of Various AIDS-related Issues by Residence (Pilot or Control District)

87 Know That a Healthy-Looking 87 Person Can Have 86 HIV 85

88 Pilot '03 Know That HIV Can Know That HIV Can 85 Control '03 Be Transmitted FromFrom Mother Mother to toChild Ch 89 Pilot '99 Control '99 88

77 Personally Know Personally Know 76 Someone Who Has HIVHIV or or a aPerson Person Who Wh 77 Has Died of AIDS 70

0 20406080100 Percent

5.5 Knowledge of a Source for Condoms

As seen in Table 5.5, 74 percent of respondents in the pilot districts said they knew of a source of supply for condoms compared with 62 percent of women in the control districts. Of those women who reported that they knew a source for condoms, 92 percent in the pilot districts and 85 percent in the control districts named a public source for condoms. Only 6 percent of respondents in both the pilot and control districts named a private medical source.

33 Table 5.5 Knowledge of condoms and sources

Percentage of women who know a source for condoms, and percent distribution of these women by type of source known, according to residence (pilot or control district), Malawi 2003 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Source of condoms Number ––––––––––––––––––––––––––––––––––––– of women Knows any Number who know a source for of Private Other source for Residence condoms women Public medical private Missing Total condoms –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Pilot districts 74.3 1,615 91.8 6.2 2.0 0.0 100.0 1,200 Control districts 61.9 1,592 84.6 6.0 9.2 0.2 100.0 985

Figure 5.3 compares levels of knowledge about sources for condom as reported in FPRHS99 and FPRHS03. Knowledge of any source for condoms remained stable at 74 percent in the pilot districts, while, in the control districts, it declined from 71 to 62 percent. Acquaintance with a public source remained stable at 92 percent in the pilot districts and increased very slightly in the control districts from 84 to 85 percent. Knowledge of private medical sources increased from 5 to 6 percent in the pilot areas but declined from 10 to 6 percent in the control districts.

Figure 5.3 Percentage of Women Who Know a Source for Condoms and Who Used a Condom During Last Sexual Intercourse by Residence (Pilot or Control District)

74 Knows a Source for 62 Condoms 74 71

92 Knows of a Public 85 Source 92 Pilot '03 84 Control '03 6 Pilot '99 Knows a Private 6 Control '99 Medical Source 5 10

17 Used a Condom 11 During Last Sex 12 11

0 20406080100120 Percent

5.6 Use of Condoms during Last Sexual Intercourse

The FPRHS03 asked all women who had had sex in the last 12 months whether they used a condom the last time they had sex. Table 5.6 shows that 17 percent of women in the pilot districts and 11 percent of women in the control districts used a condom at last sex. In Table 5.6, the expected associations with age, marital status, and education are seen. Women with a secondary level of education are more than three times as likely to have used a condom at last sex than their counterparts with no formal education. This suggests that, to a greater extent than among uneducated women, women with education possess the knowledge and skills to negotiate safer sex practices.

Table 5.6 Use of condoms

Among women who had sex in the last 12 months, the percentage who used a condom at last sex, by residence (pilot or control district), Malawi 2003 –––––––––––––––––––––––––––––––––––––––––––––– Used a Background condom Number characteristic at last sex of women –––––––––––––––––––––––––––––––––––––––––––––– Age 15-19 20.2 347 20-24 18.8 622 25-29 13.1 467 30-49 10.1 930

Residence Pilot districts 17.4 1,204 Control districts 11.4 1,162

Marital status Currently in union 12.6 2,073 Not currently in union 27.3 293

Education No education 7.2 470 Primary 15.2 1,672 Secondary 24.1 224

All women 14.5 2,366

Figure 5.3 shows changes in the prevalence of condom use during last sexual intercourse between 1999 and 2003. Whereas use remained constant at 11 percent in the control districts, it increased from 12 to 17 percent in the pilot areas.

35 APPENDIX A

FAMILY PLANNING AND REPRODUCTIVE HEALTH SURVEY STAFF, 2003

POPULATION AND FAMILY PLANNING PROJECT STAFF Mrs. Prisca C. Masepuka Project Coordinator Coordinator, Central Region Mr. Hudson Kubwalo I.E.C. Specialist Coordinator, Southern Region Ms. Juliana Lunguzi CBDA Officer Coordinator, Northern Region Mr. L. B. Lokosang M&E Specialist Survey Coordinator and Data Processing Supervisor Mr. Jameson Ndawala Assistant Commissioner, NSO Technical Advisor (South) Mr. Richmond Chinula NSO Officer Technical Advisor (Northern Region) Mr. Lewis Magombo NSO Officer (retired) Technical Adivisor (Central Region)

DISTRICT FAMILY PLANNING COORDINATORS Mrs. Ethel Nyirenda Chitipa Mrs. Loky T. Munkhondya Karonga Ms. D. M. Mpando Chiradzulu Mrs. E. R. Banda Dowa Mrs. Judith Chimenya Mulanje Mr. Bonnifacio Ndovi Ntchisi

INTERVIEWERS

Chitipa District K. Fweta R. Ghambi Chrissie Msukwa K. Kanyika E. Mubandia W. Simkonda J. Mukhala Ms. M. Mwanza A. Mtambo O. Mnyenyembe L. Mvula V. Kaonga B. K. Chabinga V.G. Ng’ambi J. Singogo M. Sikwese J. Munthali M. Mogha J. Simwaka J Sichula M. Chizumila S. Kapenda V. Ng’ambi V. Msukwa S. Mwenitete Karonga District M W Gondeva W. M. Kawira B. R. Luhanga W. M. Ngwira E. A. Nyondo L. Mwanyongo A. N. L. Mwangongo J. Munthali J. L. Mkandawire L. Mwandosya A. Mwanyengo R. M. Mkandawire H. Mwakikunga C. Mwandosya E. T. Msukwa I. P. Chungwa A.K.D. Mwenifumbo D. O. Y. Msopole H. A. Milanzi Y. G. Kaghange E. Chihana A. Mulambia S. R. Kumwenda L.S.D. Kaninyoghe M. F. Msokwa

Ntchisi District Nkhambule Chindungwa Mkanthama Kadewere Mazoe Kafalirani Nthombozi Manjawira S. Sankhulani Chikuni Kamangeni D. Ngwira Kapimphi Kanyenga P. Chimsasa Tibula Mwale Mbiridzongwe M. Msakambewa Chabwera J. K. Banda R. Sogolani Chiphambo Kenani J. Mchere Dowa District E. Mapira C. P. Nkhoma Chiphaka E. J. Diziye Chimbalu Wandawanda Chawiya Mchawa Bokola B. Katyole O. Banda M. Chinkhuzi R. Malata S. Kanyenda H. Magombo L. Kongwani U. C. Phiri Kaphiri L. Chisamba H.K. Banda G. Chinseu M. Kholovala Kantepa H. Yohane B. Kajawa Chiradzulu District C. B. Mussa Zaunda A. Mahenye J. L. Majawa M. Namavina D. Likambale L. Douglas L. Nyangulu E.H. Liwonde J. Chalimba D.G. Phiri P. Bwanali L.E. Malisawo W. Masina D. Thowa M. F. Kandaya A. Chirwa M. N. Y. Msumba J. Damiano E. Njala 124. L. Muphuwa J. Sajeni S. Duka H. Mathumula I.G. Manyamula Mulanje District N. Themuka D. Mawira C. Simbi F. Kandiero F. Kapusa C. Maliwa F. Mang’ani B. Katsabola L. Kanjala Mr. I. Kayange S. Kaziputa P. Liwonde Mr. A. Mbawa G. Masanjala E. Nakali J. Thangalimodzi G. Chakwana J. Mapeto M. Kausiwa C. Luka C. Nkhoma B. Mtambalika W. Banda L. Mumba B. Mathuli

TEAM SUPERVISORS Mr. Moses B. K. Chavula District Env. Health Officer, Chitipa D.H. Mr. T. K. C. Moyo Assistant Env. Health Officer¸ Nthalire H.C Mr. Jussie G. L. Nyirenda Assistant Env. Health Officer, Chitipa D.H Mr. Mordecai S. Mbowe Environmental Health Officer, Kameme H.C Mrs. Mwawi Chipeta Community Health Nurse, Chitipa D.H. Mr. K.M. Kumwenda District Env. Health Officer, Karonga D.H. Mr. Peter Collins Kamuloni Assistant Env. Health Officer, Karonga D.H. Mr. Reinford M.K. Sichinga Assistant Env. Health Officer, Karonga D.H. Mr. Elias B. C. Phiri Assistant Env. Health Officer. Karonga D.H. Mrs. Margaret Nazombe Community Health Nurse, Karonga D.H. Mr. Young Samanyika District Env. Health Officer, Ntchisi D. H. Mr. Kawada Ombani Environmental Health Officer, Ntchisi D. H. Mr. Kingsley Takomana Environmental Health Officer, Nthondo H.C. Mr. Alexander Mwangonde Environmental Health Officer, Mzandu H.C. Mrs. Ruth Chizimba Community Health Nurse, Ntchisi D. H. Mr. A. J. Chikaphonya Senior Env. Health Officer, Dowa D.H. Mr. M. Malemia Assistant Env. Health Officer, Dowa D.H. Mr. Danvan G. Kapalamula Health Assistant, Mponela R.H. Mr. M. F. Kantchere Assistant Env. Health Officer, Mponela R.H. Mrs. A. M. Mbenjere Community Health Nurse, Mponela R.H. Mr. Austin C. Zgambo District Env. Health Officer, Chiradzulu D.H. Mr. Charles F. M. D. Waleza Assistant Env. Health Officer, Chiradzulu D.H. Mr. Jimmy K. Makoka Senior Env. Health Officer, Chiradzulu D.H. Mr. Rodrick Yapuwa Health Assistant, Chiradzulu D.H. Mrs. Dorothy Mphaya Community Health Nurse, Chiradzulu D.H. Mr. Maynard M.K. Theu District Env. Health Officer, Mulanje D.H. Mr. Humphrey D. Mussa Environmental Health Officer, Mulanje D.H. Mr. Ronex Z. Nguwo Environmental Health Officer, Mulanje D.H. Mr. Little E.M. Banda Environmental Health Officer, Mulanje D.H. Mrs. Dora Sakwata Community Health Nurse, Mulanje D.H.

DATA PROCESSING STAFF Mr. Han Raggers Data Processing Consultant (MACRO Int.) Mr. L. B. Lokosang M&E Specialist (POP/FP Project) Mr. H. Y. Chibade Data Entry Operator Mr. Vincent Masoo Data Entry Operator Miss Veronica Kayanula Data Entry Operator Mr. Phoenix Mkuliwa Data Entry Operator Mrs. Maclina Chatata Data Entry Operator Ms. Patricia Zakeyo Data Editor Mr. James Kasereka-Kyusa Supervisor

APPENDIX B

QUESTIONNAIRES

FAMILY PLANNING AND REPRODUCTIVE HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME ______

NAME OF HOUSEHOLD HEAD ______

EA NUMBER ......

HOUSEHOLD NUMBER ......

DISTRICT NAME AND NUMBER______

INTERVIEWER VISITS

1 2 3 FINAL VISIT

DAY DATE ______

MONTH INTERVIEWER’S NAME ______YEAR

RESULT* ______NAME

RESULT

NEXT DATE: TOTAL NO. OF VISITS: VISIT: TIME:

*RESULT CODES: 1. COMPLETED TOTAL 2. NO HOUSEHOLD MEMBER AT HOME OF NO COMPETENT RESPONDENT AT HOME PERSONS AT TIME OF VISIT IN HOUSE- 3. ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME HOLD 4. POSTPONED 5. REFUSED 6. DWELLING VACANT OR ADDRESS NOT A DWELLING TOTAL 7. DWELLING DESTROYED ELIGIBLE 8. DWELLING NOT FOUND WOMEN 9. OTHER ______

(SPECIFY) LINE NO. OF HOUSEHOLD RESPOND- ENT

SUPERVISOR OFFICE EDITOR KEYED BY

NAME ______NAME ______DATE ______DATE ______

LANGUAGE OF INTERVIEW: CHICHEWA...... 1 LANGUAGE OF QUESTIONNAIRE: ENGLISH ...... 3 TUMBUKA ...... 2 OTHER ______...... 3

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.

LINE USUAL RESIDENTS AND RELATIONSHIP SEX RESIDENCE AGE ELIGIBILITY NO. VISITORS TO HEAD OF HOUSEHOLD

Please give me the names of What is the Is (NAME) Does (NAME) Did (NAME) How old is CIRCLE LINE the persons who usually live relationship of male or usually live stay here (NAME)? NUMBER OF ALL in your household and guests (NAME) to the female? here? last night? WOMEN AGE 15-49 of the household who stayed head of the here last night, starting with household?* the head of the household.

(1) (2) (3) (4) (5) (6) (7) (8)

M F YES NO YES NO IN YEARS

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 01 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 01

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 02 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 02

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 03 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 03

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 04 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 04

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 05 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 05

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 06 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 06

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 07 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 07

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 08 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 08

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 09 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 09

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 10 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 10

* CODES FOR Q.3 01 = HEAD 05 = GRANDCHILD 10 = OTHER RELATIVE RELATIONSHIP TO HEAD OF 02 = WIFE OR HUSBAND 06 = PARENT 11 = ADOPTED/FOSTER/ HOUSEHOLD: 03 = SON OR DAUGHTER 07 = PARENT-IN-LAW STEPCHILD 04 = SON-IN-LAW OR 08 = BROTHER OR SISTER 12 = NOT RELATED DAUGHTER-IN-LAW 98 = DON’T KNOW

LINE USUAL RESIDENTS AND RELATIONSHIP SEX RESIDENCE AGE ELIGIBILITY NO. VISITORS TO HEAD OF HOUSEHOLD

Please give me the names of What is the Is (NAME) Does Did How old is CIRCLE LINE the persons who usually live relationship of male or (NAME) (NAME) (NAME)? NUMBER OF ALL in your household and guests (NAME) to the female? usually stay here WOMEN AGE 15-49 of the household who stayed head of the live here? last night? here last night, starting with household?* the head of the household.

(1) (2) (3) (4) (5) (6) (7) (8)

M F YES NO YES NO IN YEARS

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 11 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 11

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 12 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 12

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 13 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 13

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 14 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 14

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 15 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 15

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 16 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 16

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 17 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 17

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 18 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 18

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 19 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 19

┌───┬───┐ ┌───┬───┐ │░░░│░░░│ │░░░│░░░│ 20 └───┴───┘ 1 2 1 2 1 2 └───┴───┘ 20

TICK HERE IF CONTINUATION SHEET USED

┌──┐ └──┘

Just to make sure that I have a complete listing:

1) Are there any other persons such as small children or infants that we have not listed? YES ENTER EACH IN TABLE NO

In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here? YES ENTER EACH IN TABLE NO

3) Are there any guests or temporary visitors

staying here, or anyone else who slept here last night, who have not been listed? YES ENTER EACH IN TABLE NO

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

21 What is the main source of drinking water for members of your PIPED WATER household? PIPED INTO DWELLING...... 11 23 PIPED INTO YARD/PLOT ...... 12 23 PUBLIC TAP ...... 13 WELL WATER PROTECTED WELL/BOREHOLE ...... 21 UNPROTECTED WELL...... 22 PUBLIC TAP ...... 23 SURFACE WATER SPRING ...... 41 RIVER/STREAM ...... 42 POND/LAKE...... 43 DAM ...... 44 RAINWATER...... 51 23 OTHER 96 (SPECIFY)

22 How long does it take you to go there, get water, and come back? ┌───┬───┬───┐ MINUTES...... │░░░│░░░│░░░│ └───┴───┴───┘ ON PREMISES ...... 996

23 What kind of toilet facility do most members of your household use? FLUSH TOILET...... 11 PIT TOILET/LATRINE TRADITIONAL PIT TOILET ...... 21 NO FACILITY/BUSH/FIELD...... 31 25

OTHER 96 (SPECIFY)

24 Do you share this facility with other households? YES ...... 1 NO...... 2

25 Does your household have: YES NO Electricity? ELECTRICITY...... 1 2 A radio? RADIO...... 1 2 Bed net? BED NET...... 1 2

26 What type of fuel does your household mainly use for cooking? ELECTRICITY...... 01 KEROSENE ...... 04 COAL ...... 05 CHARCOAL ...... 06 FIREWOOD, STRAW ...... 07 DUNG...... 08

OTHER 96 (SPECIFY)

27 MAIN MATERIAL OF THE FLOOR. EARTH/SAND...... 11 WOOD PLANKS ...... 21 PALM/BAMBOO...... 22 RECORD OBSERVATION. POLISHED WOOD ...... 31 CERAMIC TILES...... 33 CEMENT...... 34 CARPET...... 35

OTHER 96 (SPECIFY)

FAMILY PLANNING AND REPRODUCTIVE HEALTH SURVEY WOMAN’S QUESTIONNAIRE

IDENTIFICATION

PLACE NAME ______

NAME OF HOUSEHOLD HEAD ______

EA NUMBER ......

HOUSEHOLD NUMBER ......

DISTRICT NAME AND NUMBER______

NAME AND LINE NUMBER OF WOMAN ______

INTERVIEWER VISITS

1 2 3 FINAL VISIT

DAY DATE ______

MONTH INTERVIEWER’S NAME ______YEAR

RESULT* ______NAME ______

RESULT

NEXT DATE: TOTAL NO. OF VISIT: TIME: VISITS:

*RESULT CODES: 1 COMPLETED 4 REFUSED 2 NOT AT HOME 5 PARTLY COMPLETED 7 OTHER ______3 POSTPONED 6 INCAPACITATED (SPECIFY)

SUPERVISOR OFFICE EDITOR KEYED BY

NAME ______NAME DATE ______

DATE ______

LANGUAGE OF INTERVIEW: CHICHEWA ...... 1 LANGUAGE OF TUMBUKA ...... 2 QUESTIONNAIRE ENGLISH ...... 3 OTHER______...... 3

47 SECTION 1. RESPONDENT’S BACKGROUND

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

101 RECORD THE TIME. ┌───┬───┐ HOUR...... │░░░│░░░│ ├───┼───┤ MINUTES ...... │░░░│░░░│ └───┴───┘

105 In what month and year were you born? ┌───┬───┐ MONTH ...... │░░░│░░░│ └───┴───┘ DON’T KNOW MONTH ...... 98 ┌───┬───┬───┬───┐ YEAR...... │░░░│░░░│░░░│░░░│ └───┴───┴───┴───┘ DON’T KNOW YEAR ...... 9998

106 How old were you at your last birthday? ┌───┬───┐ AGE IN COMPLETED YEARS.│░░░│░░░│ COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT. └───┴───┘

107 Have you ever attended school? YES ...... 1 NO...... 2 201

108 What is the highest level of school you attended: PRIMARY...... 1 primary, secondary, or higher? SECONDARY...... 2 HIGHER ...... 3

109 How many years did you complete at that level? ┌───┬───┐ YEARS ...... │░░░│░░░│ └───┴───┘

48 SECTION 2: REPRODUCTION

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

201 Now I would like to ask about all the births you have had during your YES ...... 1 life. Have you ever given birth? NO...... 2 206

202 Do you have any sons or daughters to whom you have given birth who YES ...... 1 are now living with you? NO...... 2 204

┌───┬───┐ 203 How many sons live with you? SONS AT HOME...... │░░░│░░░│ ├───┼───┤ And how many daughters live with you? DAUGHTERS AT HOME ...... │░░░│░░░│ └───┴───┘ IF NONE, RECORD ‘00'.

204 Do you have any sons or daughters to whom you have given birth who YES ...... 1 are alive but do not live with you? NO...... 2 206

┌───┬───┐ 205 How many sons are alive but do not live with you? SONS ELSEWHERE...... │░░░│░░░│ ├───┼───┤ And how many daughters are alive but do not live with you? DAUGHTERS ELSEWHERE ...│░░░│░░░│ └───┴───┘ IF NONE, RECORD ‘00'.

206 Have you ever given birth to a boy or girl who was born alive but later died? YES ...... 1 NO...... 2 208 IF NO, PROBE: Any baby who cried or showed signs of life but survived only a few hours or days?

┌───┬───┐ 207 How many boys have died? BOYS DEAD ...... │░░░│░░░│ ├───┼───┤ And how many girls have died? GIRLS DEAD...... │░░░│░░░│ └───┴───┘ IF NONE, RECORD ‘00'.

208 SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. ┌───┬───┐ TOTAL...... │░░░│░░░│ IF NONE, RECORD ‘00'. └───┴───┘

209 CHECK 208:

Just to make sure that I have this right: you have had in TOTAL _____ births during your life. Is that correct?

PROBE AND YES NO CORRECT 201-208 AS NECESSARY.

226 Are you pregnant now? YES ...... 1

NO...... 2 301 UNSURE ...... 8

227 How many months pregnant are you? ┌───┬───┐ MONTHS...... │░░░│░░░│ └───┴───┘

49 SECTION 3. CONTRACEPTION

Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN GO DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.

301 Which ways or methods have you heard about? 302 Have you ever used FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: (METHOD)? Have you ever heard of (METHOD)?

01 FEMALE STERILIZATION Women can have an operation to avoid YES...... 1 Have you ever had an having any more children. NO...... 2 operation to avoid having any more children? YES ...... 1 NO ...... 2

02 MALE STERILIZATION Men can have an operation to avoid having YES...... 1 Have you ever had a any more children. NO...... 2 partner who had an operation to avoid having any more children? YES ...... 1 NO ...... 2

03 PILL Women can take a pill every day YES...... 1 YES ...... 1 NO...... 2 NO ...... 2

04 IUD Women can have a loop or coil placed inside them by a doctor or YES...... 1 YES ...... 1 a nurse. NO...... 2 NO ...... 2

05 INJECTIONS Women can have an injection by a health provider which YES...... 1 YES ...... 1 stops them from becoming pregnant for one or more months. NO...... 2 NO ...... 2

06 IMPLANTS Women can have several small rods placed in their upper YES...... 1 YES ...... 1 arm by a doctor or nurse which can prevent pregnancy for one or more NO...... 2 years. NO ...... 2

07 CONDOM Men can put a rubber sheath on their penis before sexual YES...... 1 YES ...... 1 intercourse. NO...... 2 NO ...... 2

08 FEMALE CONDOM Women can place a sheath in their vagina before YES...... 1 YES ...... 1 sexual intercourse. NO...... 2 NO ...... 2

09 DIAPHRAGM Women can place a diaphragm in their vagina before YES...... 1 YES ...... 1 intercourse. NO...... 2 NO ...... 2

10 FOAM OR JELLY Women can place a suppository, jelly, or cream in YES...... 1 YES ...... 1 their vagina before intercourse. NO...... 2 NO ...... 2

11 LACTATIONAL AMENORRHEA METHOD (LAM) Up to 6 months after YES...... 1 YES ...... 1 childbirth, a woman can use a method that requires that she NO...... 2 breastfeeds frequently, day and night, and that her menstrual period NO ...... 2 has not returned.

12 RHYTHM OR PERIODIC ABSTINENCE Every month that a woman is YES...... 1 YES ...... 1 sexually active she can avoid pregnancy by not having sexual NO...... 2 intercourse on the days of the month she is most likely to get pregnant. NO ...... 2

13 WITHDRAWAL Men can be careful and pull out before climax. YES...... 1 YES ...... 1 NO...... 2 NO ...... 2

14 EMERGENCY CONTRACEPTION Women can take pills up to three YES...... 1 YES ...... 1 days after sexual intercourse to avoid becoming pregnant. NO...... 2 NO ...... 2

15 Have you heard of any other ways or methods that women or men can YES...... 1 use to avoid pregnancy? (SPECIFY) YES ...... 1 NO ...... 2 (SPECIFY) NO...... 2 YES ...... 1 NO ...... 2

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

303 CHECK 302

NOT A SINGLE ‘YES’ AT LEAST ONE ‘YES’ (NEVER USED) (EVER USED) 307

304 Have you ever used anything or tried in any way to delay or avoid YES ...... 1 getting pregnant? NO...... 2 328

306 What have you used or done?

CORRECT 302 AND 303 (AND 301 IF NECESSARY).

307 Now I would like to ask you about the first time that you did something ┌───┬───┐ or used a method to avoid getting pregnant. NUMBER OF CHILDREN ...... │░░░│░░░│ └───┴───┘ How many living children did you have at that time, if any?

IF NONE, RECORD ‘00'.

308 CHECK 302 (01): WOMAN NOT WOMAN STERILIZED STERILIZED 311A

309 CHECK 226:

NOT PREGNANT PREGNANT OR UNSURE 328

310 Are you currently doing something or using any method to delay or YES ...... 1 avoid getting pregnant? NO...... 2 328

311 Which method are you using? FEMALE STERILIZATION ...... A MALE STERILIZATION...... B

PILL...... C IUD ...... D INJECTIONS...... E 311A CIRCLE ‘A' FOR FEMALE STERILIZATION. IMPLANTS ...... F CONDOM...... G 327 FEMALE CONDOM...... H DIAPHRAGM...... I IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP FOAM/JELLY ...... J INSTRUCTION FOR HIGHEST METHOD ON LIST. LACT. AMEN. METHOD ...... K

PERIODIC ABSTINENCE...... L WITHDRAWAL...... M 330

OTHER X (SPECIFY)

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

313 Where did the sterilization take place? PUBLIC SECTOR GOVT. HOSPITAL ...... 11 GOVT. HEALTH CENTER ...... 12 DISPENSARY/MATERNITY CLINIC....13 IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE MOBILE CLINIC...... 14 NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. OTHER PUBLIC 16 (SPECIFY)

PRIVATE MEDICAL SECTOR ______PRIVATE HOSPITAL ...... 21 PRIVATE HEALTH CENTRE...... 22 330 (NAME OF PLACE) DISPENSARY/MATERNITY CLINIC....23 MOBILE CLINIC...... 24 PRIVATE DOCTOR ...... 25 OTHER PRIVATE IF BOTH CODE ‘A’ AND CODE ‘B’ ARE CIRCLED IN 311, ASK 313 MEDICAL 26 ABOUT FEMALE STERILIZATION ONLY. (SPECIFY)

OTHER 96 (SPECIFY) DON’T KNOW ...... 98

327 Where did you obtain (CURRENT METHOD) the last time?1 PUBLIC SECTOR GOVT. HOSPITAL ...... 11 GOVT. HEALTH CENTRE ...... 12 DISPENSARY/MATERNITY CLINIC....13 IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE MOBILE CLINIC...... 14 NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE CBDA ...... 15 AND CIRCLE THE APPROPRIATE CODE. OTHER PUBLIC 16 (SPECIFY)

PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL ...... 21 PRIVATE HEALTH CENTRE...... 22 DISPENSARY/MATERNITY CLINIC....23 ______MOBILE CLINIC...... 24 330 PRIVATE DOCTOR ...... 25 (NAME OF PLACE) OTHER PRIVATE MEDICAL 26 (SPECIFY) OTHER SOURCE SHOP ...... 31 PHARMACY...... 32 BOTTLE SHOP ...... 33 REST HOUSE...... 34 FRIEND/RELATIVE...... 35

OTHER 96 (SPECIFY)

328 Do you know of a place where you can obtain a method of family planning? YES ...... 1 NO ...... 2 330

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

329 Where is that? PUBLIC SECTOR GOVT. HOSPITAL ...... 11 GOVT. HEALTH CENTRE...... 12 DISPENSARY/MATERNITY CLINIC ... 13 IF SOURCE IS HOSPITAL, HEALTH CENTRE, OR CLINIC, WRITE THE MOBILE CLINIC...... 14 NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE CBDA ...... 15 AND CIRCLE THE APPROPRIATE CODE. OTHER PUBLIC 16 (SPECIFY)

PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL...... 21 PRIVATE HEALTH CENTRE...... 22 DISPENSARY/MATERNITY CLINIC ... 23 ______MOBILE CLINIC...... 24 PRIVATE DOCTOR ...... 25 (NAME OF PLACE) OTHER PRIVATE MEDICAL 26 (SPECIFY) OTHER SOURCE SHOP...... 31 PHARMACY...... 32 BOTTLE SHOP...... 33 REST HOUSE...... 34 FRIEND/RELATIVE ...... 35

OTHER 96 (SPECIFY)

330 In the last 12 months, were you visited by a field worker who talked to you YES ...... 1 about family planning methods? NO...... 2 330A In the last 12 months have you been visited by a CBDA? YES ...... 1

NO...... 2 331 DON’T KNOW/UNSURE ...... 3

330B CHECK 330. IF THE RESPONSE TO 330 IS ‘NO’, CHANGE IT TO ‘YES.’

330C Did the CBDA talk to you about family planning methods? YES ...... 1 NO...... 2 331

330D Did the CBDA tell you where you can get each family planning method? YES ...... 1 NO...... 2

330E CHECK 311,

311A:

WOMAN

CURRENTLY WOMAN NOT USING A USING A METHOD METHOD 331

330F Did you learn about (CURRENT) method from the CBDA? YES ...... 1 NO...... 2

331 In the last 12 months, have you visited a health facility for care for yourself YES ...... 1 (or your children)? NO...... 2 333

332 Did any staff member at the health facility speak to you about family YES ...... 1 planning methods? NO...... 2

333 Would you say that you approve or disapprove of couples using a method APPROVE...... 1 to avoid getting pregnant? DISAPPROVE...... 2

53 DON’T KNOW/UNSURE ...... 3

SECTION 5. MARRIAGE AND SEXUAL ACTIVITY

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

501 Are you currently married or living with a man? YES, CURRENTLY MARRIED ...... 1 505 YES, LIVING WITH A MAN ...... 2

NO, NOT IN UNION...... 3

502 Have you ever been married or lived with a man? YES, FORMERLY MARRIED ...... 1

YES, LIVED WITH A MAN...... 2 515 NO...... 3

504 What is your marital status now: are you widowed, divorced, or WIDOWED...... 1 separated? DIVORCED ...... 2 515

SEPARATED ...... 3

505 Is your husband/partner living with you now or is he staying LIVING WITH HER ...... 1 elsewhere? STAYING ELSEWHERE...... 2 515 When was the last time you had sexual intercourse?

IF ‘NEVER,’ CIRCLE ‘00’ AND FOLLOW SKIP. NEVER...... 00 524

RECORD ‘YEARS AGO’ ONLY IF LAST INTERCOURSE WAS ONE OR MORE YEARS AGO. DAYS AGO ...... 1

WEEKS AGO ...... 2

MONTHS AGO ...... 3

YEARS AGO...... 4 524

516 The last time you had sexual intercourse, was a condom used?1 YES...... 1 NO...... 2

517 What is your relationship to the man with whom you last had sex? SPOUSE/COHABITING PARTNER ...... 1 524 IF MAN IS "BOYFRIEND" OR "FIANCE", ASK: MAN IS BOYFRIEND/FIANCE ...... 2 Was your boyfriend/fiance living with you when you last had sex? OTHER FRIEND ...... 3 IF YES, RECORD '1'. CASUAL ACQUAINTANCE ...... 4 IF NO, RECORD '2'. RELATIVE...... 5 COMMERCIAL SEX WORKER ...... 6

OTHER 7 (SPECIFY)

518 For how long have you had a sexual relationship with this man? DAYS AGO ...... 1

WEEKS AGO ...... 2

MONTHS AGO ...... 3

YEARS AGO...... 4

524 Do you know of a place where one can get condoms? YES...... 1

NO...... 2 601

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

525 Where is that?1 PUBLIC SECTOR GOVT. HOSPITAL...... 11 GOVT. HEALTH CENTRE...... 12 DISPENSARY/MATERNITY CLINIC ... 13 IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE MOBILE CLINIC ...... 14 THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF CBDA...... 15 SOURCE AND CIRCLE THE APPROPRIATE CODE. OTHER PUBLIC 16 (SPECIFY)

PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL...... 21 PRIVATE HEALTH CENTRE ...... 22 ______DISPENSARY/MATERNITY CLINIC ... 23 MOBILE CLINIC ...... 24 (NAME OF PLACE) PRIVATE DOCTOR...... 25 OTHER PRIVATE MEDICAL 26 (SPECIFY) OTHER SOURCE SHOP...... 31 PHARMACY ...... 32 BOTTLE SHOP...... 33 REST HOUSE ...... 34 FRIEND/RELATIVE...... 35

OTHER 96 (SPECIFY)

526 If you wanted to, could you yourself get a condom? YES...... 1 NO...... 2 DON’T KNOW/UNSURE...... 8

55 SECTION 6. FERTILITY PREFERENCES

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

601 CHECK 311/311A:

NEITHER HE OR SHE STERILIZED STERILIZED 801

602 CHECK 226:

NOT PREGNANT PREGNANT: HAVE (A/ANOTHER) CHILD ...... 1 OR UNSURE: NO MORE/NONE...... 2 604

SAYS SHE CAN’T GET PREGNANT ...... 3 801 UNDECIDED/DON’T KNOW...... 8

Now I have some questions about the Now I have some questions future. about the future.

Would you like to have (a/another) After the child you are child, or would you prefer not to have expecting now, would you like any (more) children? to have another child, or would you prefer not to have any more children?

603 CHECK 226: MONTHS...... 1

PREGNANT: NOT PREGNANT YEARS ...... 2 OR UNSURE:

How long would you like to wait from After the birth of the child you SOON/NOW ...... 993 SAYS SHE CAN’T GET now before the birth of a child? are expecting now, how long would PREGNANT ...... 994 you like to wait before the birth AFTER MARRIAGE ...... 995

of another child? 801 OTHER______996

SPECIFY

DON’T KNOW ...... 998

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

604 CHECK 226:

NOT PREGNANT PREGNANT:

OR UNSURE: 801

605 CHECK 310: USING A METHOD

NOT CURRENTLY NOT ASKED: CURRENTLY USING: 801 USING:

606 CHECK 603:

NOT ASKED: 24 OR MORE MONTHS OR 0-23 MONTHS OR

2 OR MORE YEARS: 0-1 YEAR: 801

607 CHECK 602: NOT MARRIED ...... A

WANTS WANTS NO FERTILITY-RELATED REASONS A/ANOTHER (MORE) NOT HAVING SEX...... B CHILD CHILDREN INFREQUENT SEX...... C MENOPAUSAL/HYSTERECTOMY...... D SUBFECUND/INFECUND ...... E POSTPARTUM AMENORRHEIC ...... F BREASTFEEDING...... G FATALISTIC...... H

You have said that you do not You have said that you do not want OPPOSITION TO USE want (a/another) child soon, any (more) children, but you are not RESPONDENT OPPOSED ...... I but you are not using any using any method to avoid pregnancy. HUSBAND/PARTNER OPPOSED...... J method to avoid pregnancy. Can you tell me why? OTHERS OPPOSED ...... K Can you tell me why? RELIGIOUS PROHIBITION ...... L

LACK OF KNOWLEDGE RECORD ALL MENTIONED. KNOWS NO METHOD...... M KNOWS NO SOURCE...... N

METHOD-RELATED REASONS HEALTH CONCERNS ...... O FEAR OF SIDE EFFECTS...... P LACK OF ACCESS/TOO FAR ...... Q COST TOO MUCH...... R INCONVENIENT TO USE...... S INTERFERES WITH BODY’S NATURAL PROCESSES...... T

OTHER X (SPECIFY) DON’T KNOW ...... Z

57 SECTION 8: AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

801 Now I would like to talk about something else. YES ...... 1 Have you ever heard of the virus HIV or an illness called AIDS? NO...... 2 821

802 Is there anything a person can do to avoid getting infected with HIV, YES ...... 1 which is the virus that causes AIDS? NO...... 2 809 DON’T KNOW ...... 8

803 What can a person do? ABSTAIN FROM SEX ...... A USE CONDOMS ...... B LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER...... C LIMIT NUMBER OF SEXUAL PARTNERSD Anything else? AVOID SEX WITH PROSTITUTES...... E AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS ...... F AVOID SEX WITH HOMOSEXUALS...... G AVOID SEX WITH PERSONS WHO RECORD ALL MENTIONED. INJECT DRUGS INTRAVENOUSLY ....H AVOID BLOOD TRANSFUSIONS ...... I AVOID INJECTIONS ...... J AVOID KISSING...... K AVOID MOSQUITO BITES ...... L SEEK PROTECTION FROM TRADITIONAL HEALER...... M AVOID SHARING RAZORS/BLADES...... N

OTHER W (SPECIFY)

OTHER X (SPECIFY) DON’T KNOW ...... Z

804 Can people protect themselves from getting the AIDS virus by having YES ...... 1 just one sex partner who has no other partners? NO...... 2 DON’T KNOW ...... 8

805 Can people protect themselves from getting the AIDS virus by avoiding YES ...... 1 mosquito bites? NO...... 2 DON’T KNOW ...... 8

806 Can people protect themselves from getting the AIDS virus by using a YES ...... 1 condom every time they have sex? NO...... 2 DON’T KNOW ...... 8

807 Can people protect themselves from getting the AIDS virus by not YES ...... 1 sharing food with a person who has AIDS? NO...... 2 DON’T KNOW ...... 8

808 Can people protect themselves from getting the AIDS virus by YES ...... 1 abstaining completely from sex? NO...... 2 DON’T KNOW ...... 8

809 Is it possible for a healthy-looking person to have the AIDS virus? YES ...... 1 NO...... 2 DON’T KNOW ...... 8

811 Do you know someone personally who has the virus that causes AIDS YES ...... 1 or someone who died from AIDS? NO...... 2

812 Can the virus that causes AIDS be transmitted from a mother to a YES ...... 1 child? NO...... 2 821 DON’T KNOW ...... 8

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

813 When can the virus that causes AIDS be transmitted from a mother to DURING PREGNANCY ...... A a child? AT DELIVERY...... B DURING BREASTFEEDING...... C Any others times? OTHER TIMES...... D RECORD ALL RESPONSES. DON’T KNOW ...... Z

814 CHECK 330A

WOMAN VISITED BY WOMAN NOT BY A CBDA IN LAST VISITED BY 12 MONTHS CBDA 821

815 You said that you have been visited by a CBDA in the last 12 months. YES ...... 1 When the CBDA visited you did he/she discuss how to protect yourself from getting the virus which causes AIDS? NO...... 2

821 RECORD THE TIME. ┌───┬───┐ HOUR...... │░░░│░░░│ ├───┼───┤ MINUTES ...... │░░░│░░░│ └───┴───┘

59 INTERVIEWER’S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR’S OBSERVATIONS

NAME OF THE SUPERVISOR:______DATE: ______

EDITOR’S OBSERVATIONS

NAME OF EDITOR:______DATE: ______