Egypt Demographic and Health Survey 2008

Egypt Demographic and Health Survey 20082008
Ministry of Health
The 2008 Egypt Demographic and Health Survey (2008 EDHS) was conducted on behalf of the Ministry of Health by El- Zanaty and Associates. The Central Laboratory at the Ministry of Health was responsible for the hepatitis C testing component of the survey. The 2008 EDHS is part of the worldwide MEASURE DHS project which is funded by the United States Agency for International Development (USAID). USAID/Cairo was the main contributor of funding for the survey. Support for the survey was also provided by UNICEF. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID and UNICEF. Additional information about the 2008 EDHS may be obtained from the Ministry of Health, 3 Magles El Shaab Street, Cairo, Egypt; Telephone: 20-2-27948555 and Fax: 20-2-27924156. Information about DHS surveys may be obtained from the MEASURE DHS Project, Macro International, 11785 Beltsville Drive, Calverton, MD 20705 USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: [email protected], Internet: http://www.measuredhs.com.
Recommended citation: El-Zanaty, Fatma and Ann Way. 2009. Egypt Demographic and Health Survey 2008. Cairo, Egypt: Ministry of Health, El-Zanaty and Associates, and Macro International.
Contents | iii
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Contents | vii
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Tables and Figures | ix
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Table 18.4 Coverage of hepatitis C testing among the de facto population age 15-59 years by age .................................................................................... 249 Table 18.5 Coverage of hepatitis C testing among the de facto population age 15-59 years by selected background characteristics ................................... 250 Table 18.6 Outcome of testing for hepatitis C virus (HCV) among the population age 15-59 years by age .................................................................................... 252 Table 18.7 Outcome of testing for hepatitis C virus (HCV) among the population age 15-59 years by socioeconomic characteristics ............................................ 254 Table 18.8 Outcome of testing for hepatitis C virus (HCV) among the population age 15-59 years by lifetime history of medical procedures and injections ......... 256 Figure 18.1 Percentage of Women and Men Positive on the RNA Test for the Hepatitis C Virus by Age .................................................................................. 253 Figure 18.2 Percentage of Women and Men Age 15-59 Positive on HVC-RNA Test by Receipt of Injection to Treat Schistomiasis ................................................... 258 CHAPTER 19 KNOWLEDGE AND ATTITUDES ABOUT HIV/AIDS Table 19.1.1 Knowledge of AIDS by background characteristics: Women............................. 260 Table 19.1.2 Knowledge of AIDS by background characteristics: Men .................................. 261 Table 19.2 Comprehensive knowledge of AIDS among youth by background characteristics .................................................................................................. 262 Table 19.3.1 Knowledge of prevention of mother-to-child transmission (PMTCT) of HIV by background characteristics: Women..................................................... 264 Table 19.3.2 Knowledge of prevention of mother-to-child transmission (PMTCT) of HIV by background characteristics: Men .......................................................... 265 Table 19.4.1 Accepting attitudes toward those living with HIV by background characteristics: Women.................................................................................... 266 Table 19.4.2 Accepting attitudes toward those living with HIV by background characteristics: Men ......................................................................................... 267 Table 19.5 Knowledge of a place where HIV testing available by background characteristics .................................................................................................. 268 Table 19.6.1 Sources of information about AIDS by background characteristics: Women ..... 269 Table 19.6.2 Sources of information about AIDS by background characteristics: Men........... 270 Figure 19.1 Percentage of Youth and Young Adults with Comprehensive AIDS Knowledge by Sex and Urban-Rural Residence ................................................ 263 CHAPTER 20 HEALTH CARE EXPENSES AND HEALTH CARE COVERAGE Table 20.1 Visit to health provider recently ....................................................................... 272 Table 20.2 Expenses for last health care consultation......................................................... 273 Table 20.3 Total expenses incurred for last health care consultation by type of provider consulted........................................................................................... 274 Table 20.4 Hospital stays in past 12 months ...................................................................... 275 Table 20.5 Total expenses incurred relating to last hospitalization ..................................... 276 Table 20.6 Total expenses incurred relating to antenatal care services ............................... 276 Table 20.7 Total expenses incurred relating to delivery services......................................... 277 Table 20.8 Total expenses incurred relating to postnatal care services................................ 277
Tables and Figures | xvii
Table 20.9 Health insurance coverage............................................................................... 278 Figure 20.1 Percentage of Women and Men Age 15-59 Covered by Health Insurance, According to Place of Residence ...................................................................... 279 APPENDIX B SAMPLE DESIGN Table B.1 Sample allocation for the 2008 EDHS .............................................................................293 Table B.2.1 Sample implementation for ever-married women component of the 2008 EDHS ..................................................................................................... 294 Table B.2.2 Sample implementation for health issues component of the 2008 EDHS.......... 295 APPENDIX C ESTIMATES OF SAMPLING ERRORS Table C.1 List of selected variables for sampling errors, Egypt 2008.................................. 298 Table C.2 Sampling errors for National sample, Egypt 2008 ............................................. 299 Table C.3 Sampling errors for Urban sample, Egypt 2008................................................. 300 Table C.4 Sampling errors for Rural sample, Egypt 2008 .................................................. 301 Table C.5 Sampling errors for Urban Governorates sample, Egypt 2008 ........................... 302 Table C.6 Sampling errors for Lower Egypt sample, Egypt 2008........................................ 303 Table C.7 Sampling errors for Lower Egypt, Urban sample, Egypt 2008............................ 304 Table C.8 Sampling errors for Lower Egypt, Rural sample, Egypt 2008 ............................. 305 Table C.9 Sampling errors for Upper Egypt sample, Egypt 2008 ....................................... 306 Table C.10 Sampling errors for Upper Egypt, Urban sample, Egypt 2008 ........................... 307 Table C.11 Sampling errors for Upper Egypt, Rural sample, Egypt 2008 ............................. 308 Table C.12 Sampling errors for Frontier Governorates sample, Egypt 2008......................... 309 APPENDIX D DATA QUALITY TABLES Table D.1 Household age distribution .............................................................................. 311 Table D.2 Age distribution of eligible and interviewed women ......................................... 312 Table D.3 Completeness of reporting ............................................................................... 312 Table D.4 Reporting of age at death in days ..................................................................... 313 Table D.5 Reporting of age at death in months................................................................. 314 Table D.6 Births by calendar years ................................................................................... 315 APPENDIX E NUTRITIONAL STATUS OF CHILDREN: 2008 EDHS DATA ACCORDING TO THE NCHS/CDC/WHO INTERNATIONAL REFERENCE POPULATION Table E.1 Nutritional status of children by children's characteristics according to the NCHS/CDC/WHO International Reference Population .............................. 317 Table E.2 Nutritional status of children by mother's characteristics according to the NCHS/CDC/WHO International Reference Population .............................. 318
xviii | Tables and Figures
Table E.3 Trends in nutritional status of children according to the NCHS/CDC/WHO International Reference Population .................................................................. 319 Figure E.1 Trend in Nutritional Status of Young Children, Egypt 1992-2008 (NCHS/CDC/WHO Reference Population)....................................................... 319
Preface | xix
PREFACE
Health for all is the main health objective of the Egyptian government. To monitor and evaluate progress toward the achievement of this goal, reliable data are needed. These data come from two primary sources: the health service delivery system (service-based data) and the community (household-based data). The two types of data complement each other in enhancing the information available to monitor progress in the health sector.
Beginning in 1980, a number of household surveys have been carried out in Egypt to obtain data
from the community on the current health situation, including a series of Demographic and Health Sur- veys of which the 2008 EDHS is the most recent. The results of the 2008 EDHS show that several key maternal and child health indicators including antenatal care coverage, medical assistance at delivery, and infant and child mortality have improved. The survey also found that family planning use is rising and fertility is continuing to decline although at a slow pace.
In addition, the 2008 Egypt DHS collected information relating to other health issues that Egypt
is facing including knowledge and practices relating to avian influenza and the prevalence of high blood pressure among the adult population. By collecting and testing blood samples for the hepatitis C virus from respondents, the survey also provides the first nation-wide data on the prevalence of infection with the hepatitis C virus among the Egyptian population age 15-59 years.
The findings of the 2008 EDHS together with service-based data are very important for measur-
ing the achievements of the health program to date as well as for planning future interventions to address Egypt’s health challenges. Based on the above-mentioned considerations, it is very important that the re- sults of the 2008 EDHS should be widely disseminated at different levels of health management, in the central offices as well as local governments, and to the community at large.
Prof. Dr. Hatem El-Gabaly Minister of Health
Acknowledgments | xxi
ACKNOWLEDGMENTS
The 2008 Egypt Demographic and Health Survey continues the long-standing commitment and efforts in Egypt to obtain data on fertility, contraceptive practice and maternal and child health. The focus on avian influenza, hepatitis C and adult health issues including hypertension reflects the need to obtain data to better address these challenges. Overall, the wealth of demographic and health data that the survey provides will help in charting future directions for the population and health programs.
This important survey could not have been implemented without the active support and dedicated
efforts of a large number of institutions and individuals. The support and approval of H.E. Prof. Dr. Hatem El-Gabaly was instrumental in securing the implementation of the EDHS.
USAID/Cairo through its bilateral health and population projects was the main contributor of
funding for the survey. UNICEF also provided financial support. Technical assistance came from the USAID-sponsored MEASURE DHS project.
I am deeply grateful to the Ministry of Health (MOH) staff who contributed to the successful
completion of this project, especially Dr.Nasr EL-Sayed, Minister Assistant of Primary Health Care, Pre- vention, and Family Planning, who provided strong continuing support to the project and has shown great interest in the survey results. Special thanks also go to Dr. Amr Kandil, Under Secretary of Preventive Affairs, for his continuous support during the survey implementation.
I also gratefully acknowledge the Population and Health Office staff at USAID/Cairo, especially
Ms. Holly Fluty Dempsey, Director of the Population and Health Office, and Ms. Shadia Attia, Research and Monitoring Advisor, Population and Health Office, for their support and valuable comments through- out the survey activities. I would like to thank the administrative staff at USAID and the American Em- bassy who helped to ensure that the equipment and supplies used for the hepatitis C component were available on time to start the fieldwork.
I also acknowledge with gratitude Mr. Dennis Arends, Chief of Social Policy Monitoring and
Evaluation, and Ms. Manar Soliman, Senior Program Assistant, UNICEF, for their support. The Hepatitis C testing was carried out at the Central Health Laboratory (MOH). I would like to
thank Dr. Aly Abdelstar, Dr. Amal Naguib, and Dr. Ahmed Safwat at the Central Laboratory for their dedication in completing the testing in a very timely fashion.
I would also like to thank Dr. Mohamed Aly Saber and Dr. Effat El-Sherbiny at the Theodor Bil-
harz Research Institute (TBRI) for the support that TBRI provided during the quality assurance testing. Dr. Ann Way of Macro International, who worked closely with us on all phases of EDHS, de-
serves special thanks for all her efforts throughout the survey. My thanks also are extended to Dr. Alfredo Aliaga for his advice and guidance in designing the sample. Ms. Jeanne Cushing deserves my deepest thanks for her assistance in data processing and tabulation required for this report. Ms. Jasbir Sangha pro- vided invaluable assistance with the hepatitis C testing component of the survey.
Special thanks extend to the staff at the family planning sector/MOH for their financial and ad-
ministrative support.
xxii | Acknowledgments
I would like to express my appreciation for all the senior, office, and field staff at El-Zanaty and Associates for the dedication and skill with which they performed their tasks.
Finally, I would like to express my appreciation to all households and participants who responded
in the survey; without their participation this survey would have been impossible. Fatma El-Zanaty Technical Director
Summary of Findings | xxiii
SUMMARY OF FINDINGS The 2008 Egypt Demographic and Health (2008 EDHS) Survey is the ninth in a series of Demographic and Health Surveys conducted in Egypt. The 2008 EDHS was undertaken to pro- vide estimates for key population indicators in- cluding fertility, contraceptive use, infant and child mortality, immunization levels, maternal and child health, and nutrition. To obtain this information, a nationally representative sample of 16,527 ever-married women age 15-49 was interviewed. The 2008 EDHS also collected information on a number of other health topics from 6,578 women and 5,430 men age 15-59 living in a subsample of one in four of the households sur- veyed. Among the key topics covered in these interviews were knowledge and awareness of avian influenza, HIV/AIDS and hepatitis C; pre- vious history of hypertension, cardiovascular illness diabetes and liver disease; attitudes and behavior with respect to female circumcision; health care costs; and health insurance coverage. In addition to the interview results, blood pressure measurements and blood samples for hepatitis C testing were obtained from women and men age 15-59 interviewed in the special health issues component of the survey. Height and weight measures were collected for children under age six and never-married youths and young adults age 10-19 years in all households in the survey. In the subsample of households selected for the health issues survey, these measurements were also obtained for all women and men age 20-59 while in the remaining households in the sample, measurements were recorded only for ever-married women age 20-49. FERTILITY BEHAVIOR
Levels, Trends and Differentials. The fer-
tility rate in the 2008 EDHS was 3.0 births per woman, only very slightly lower than the rate
observed in the 2005 EDHS (3.1 births per woman). In rural areas, the fertility rate is 3.2 births, around 20 percent higher than the rate in urban areas (2.7 births). Fertility levels are highest in Upper Egypt (3.4 births) and in the Frontier Governorates (3.3 births) and lowest in the Urban Governorates (2.6 births). Education is strongly associated with lower fertility as is wealth. The fertility rate decreases from a level of 3.4 births among women in the lowest wealth quintile to 2.7 births among women in the highest quintile.
Age at Marriage. One of the factors influencing
the on-going fertility decline in Egypt has been the steady increase in the age at which women marry. Currently, the median age at first marriage among women age 25-29 is 21.2 years.
One of the most important effects of the increase
in the age at first marriage has been a reduction in adolescent fertility. Adolescent childbearing carries higher risks of morbidity and mortality for the mother and child, particularly when the mother is under age 18. At the time of the 2008 EDHS, 10 per- cent of women age 15-19 had given birth or were pregnant with their first child.
FAMILY PLANNING USE
Family Planning Knowledge and Attitudes.
Widespread awareness of family planning methods has been a crucial element in the successful expan- sion of family planning use in Egypt. The 2008 EDHS found that all currently married women age 15-49 knew about at least one family planning method, and the average woman was aware of at least 6 methods. Coverage of family planning IEC efforts is widespread. However, only 67 percent of married women had heard or seen a family planning message during the six months prior to the 2008 EDHS, which is substantially lower than the level of exposure to family planning messages reported in 2005 EDHS (91 percent).
xxiv | Summary of Findings
Family planning has broad support among Egyptian couples. Most ever-married women age 15-49 (93 percent) consider it appropriate for a couple to begin family planning use after they have their first child. However, very few women who approve of family planning use (2 percent) think that it is appropriate for a newly married couple to use contraception to delay the first pregnancy.
Levels and Trends. The Egyptian govern-
ment’s commitment to providing widely acces- sible family planning services has been a very important factor in the on-going fertility decline. Contraceptive use levels more than doubled in Egypt between 1980 and 2003, from 24 percent to 60 percent. The 2008 EDHS results indicate that the contraceptive use remains stable at 60 percent.
The IUD continues to be by far the most
widely used method; 36 percent of married women were relying on the IUD, 12 percent on the pill, and 7 percent on injectables.
Differentials in Use. As expected, given the
nearly universal disapproval of family planning use before the first birth, less than 1 percent of currently married women who had not yet had a child were using at the time of 2008 EDHS. Use rates increased rapidly with family size; 46 per- cent of women with one child were using and use rates peaked at 76 percent among women with 3 children.
Use rates exceeded 60 percent in the Urban
Governorates, in both urban and rural areas in Lower Egypt, and in urban areas in Upper Egypt. In contrast, 48 percent of currently mar- ried women were using in rural Upper Egypt and 52 percent in the Frontier Governorates. Use rates rose from 55 percent of women in the low- est wealth quintile to 65 percent among women in the highest quintile.
Discontinuation of Use. A key concern for
the family planning program is the rate at which users discontinue use of contraception and their reasons for stopping. Overall, 26 percent of us- ers during the five-year prior to the 2008 EDHS discontinued using a method within 12 months
of starting use. The rate of discontinuation during the first year of use was much higher among pill us- ers (40 percent) and injectable users (37 percent) than among IUD users (12 percent). With regard to the reasons for stopping use, users were more likely to discontinue during the first year of use because they experienced side effects or had health concerns. This pattern is similar to that observed in 2005. Overall, 8 percent of users who discontinued during the first 12 months of use switched to another method within two months of the time they discon- tinued.
Provision of Services. Both government health
facilities and private sector providers play an impor- tant role in the delivery of family planning services. The 2008 EDHS showed that 60 percent all users of modern methods went to Ministry of Health or other governmental providers for their method. This repre- sents a slight increase from the situation in 2005, when 57 percent of users relied on public sector fa- cilities for their methods. Public sector providers were the principal source for the IUD and injectables at the time of the 2008 EDHS while seven in ten pill users obtained their method from a pharmacy.
The 2008 EDHS results suggest that family
planning providers are not always offering women the information necessary to make an informed choice about the method best suited to their contra- ceptive needs. In particular, around one in three us- ers of modern methods were not provided informa- tion about methods other than the one they adopt. Although side effects caused many users to discon- tinue, providers also were counselling only slightly more than half (56 percent) of the users about poten- tial side effects.
NEED FOR FAMILY PLANNING
Fertility Preferences. Many Egyptian women
are having more births than they consider ideal. Overall, 5 percent of births in the five years prior to the survey were reported to be mistimed, that is, wanted later, and 9 percent were unwanted. If Egyp- tian women were to have the number of children they consider ideal, the total fertility rate would fall from 3.0 births to 2.4 births per woman.
Unmet Need for Family Planning. Taking into
account both their fertility desire at the time of the
Summary of Findings | xxv
survey and their exposure to the risk of preg- nancy, 9 percent of currently married women were considered to have an immediate need for family planning. Unmet need is greatest among women in rural Upper Egypt, where 15 percent of women are in need of family…