Demographic and Health Survey 1990-1991

The Pakistan Demographic and Health Survey (PDHS) was fielded on a national basis between the months of December 1990 and May 1991. The survey was carried out by the National Institute of Population Studies with the objective of assisting the Ministry of Population Welfare to evaluate the Population Welfare Programme and maternal and child health services. The PDHS is the latest in a series of surveys, making it possible to evaluate changes in the demographic status of the population and in health conditions nationwide. Earlier surveys include the Pakistan Contraceptive Prevalence Survey of 1984-85 and the Pakistan Fertility Survey of 1975.

The primary objective of the Pakistan Demographic and Health Survey (PDHS) was to provide national- and provincial-level data on population and health in Pakistan. The primary emphasis was on the following topics: fertility, nuptiality, family size preferences, knowledge and use of family planning, the potential demand for contraception, the level of unwanted fertility, infant and child mortality, breastfeeding and food supplementation practices, maternal care, child nutrition and health, immunisations and child morbidity. This information is intended to assist policy makers, administrators and researchers in assessing and evaluating population and health programmes and strategies. The PDHS is further intended to serve as a source of demographic data for comparison with earlier surveys, particularly the 1975 Pakistan Fertility Survey (PFS) and the 1984-85 Pakistan Contraceptive Prevalence Survey (PCPS).

MAIN RESULTS

Until recently, fertility rates had remained high with little evidence of any sustained fertility decline. In recent years, however, fertility has begun to decline due to a rapid increase in the age at marriage and to a modest rise in the prevalence of contraceptive use. The lotal fertility rate is estimated to have fallen from a level of approximately 6.4 children in the early 1980s to 6.0 children in the mid-1980s, to 5.4 children in the late 1980s. The exact magnitude of the change is in dispute and will be the subject of further research. Important differentials of fertility include the degree ofurbanisation and the level of women's education. The total fertility rate is estimated to be nearly one child lower in major cities (4.7) than in rural areas (5.6). Women with at least some secondary schooling have a rate of 3.6, compared to a rate of 5.7 children for women with no formal education.

There is a wide disparity between women's knowledge and use of contraceptives in Pakistan. While 78 percent of currently married women report knowing at least one method of contraception, only 21 percent have ever used a method, and only 12 percent are currently doing so. Three-fourths of current users are using a modem method and one-fourth a traditional method. The two most commonly used methods are female sterilisation (4 percent) and the condom (3 percent). Despite the relatively low level of contraceptive use, the gain over time has been significant. Among married non-pregnant women, contraceptive use has almost tripled in 15 years, from 5 percent in 1975 to 14 percent in 1990-91. The contraceptive prevalence among women with secondary education is 38 percent, and among women with no schooling it is only 8 percent. Nearly one-third of women in major cities arc current users of contraception, but contraceptive use is still rare in rural areas (6 percent).

The Government of Pakistan plays a major role in providing family planning services. Eighty-five percent of sterilised women and 81 percent of IUD users obtained services from the public sector. Condoms, however, were supplied primarily through the social marketing programme.

The use of contraceptives depends on many factors, including the degree of acceptability of the concept of family planning. Among currently married women who know of a contraceptive method, 62 percent approve of family planning. There appears to be a considerable amount of consensus between husbands and wives about family planning use: one-third of female respondents reported that both they and their husbands approve of family planning, while slightly more than one-fifth said they both disapprove. The latter couples constitute a group for which family planning acceptance will require concerted motivational efforts.

The educational levels attained by Pakistani women remain low: 79 percent of women have had no formal education, 14 percent have studied at the primary or middle school level, and only 7 percent have attended at least some secondary schooling. The traditional social structure of Pakistan supports a natural fertility pattern in which the majority of women do not use any means of fertility regulation. In such populations, the proximate determinants of fertility (other than contraception) are crucial in determining fertility levels. These include age at marriage, breastfeeding, and the duration of postpartum amenorrhoea and abstinence.

The mean age at marriage has risen sharply over the past few decades, from under 17 years in the 1950s to 21.7 years in 1991. Despite this rise, marriage remains virtually universal: among women over the age of 35, only 2 percent have never married. Marriage patterns in Pakistan are characterised by an unusually high degree of consangninity. Half of all women are married to their first cousin and an additional 11 percent are married to their second cousin.

Breasffeeding is important because of the natural immune protection it provides to babies, and the protection against pregnancy it gives to mothers. Women in Pakistan breastfeed their children for an average of20months. Themeandurationofpostpartumamenorrhoeais slightly more than 9 months. After tbebirth of a child, women abstain from sexual relations for an average of 5 months. As a result, the mean duration of postpartum insusceptibility (the period immediately following a birth during which the mother is protected from the risk of pregnancy) is 11 months, and the median is 8 months. Because of differentials in the duration of breastfeeding and abstinence, the median duration of insusceptibility varies widely: from 4 months for women with at least some secondary education to 9 months for women with no schooling; and from 5 months for women residing in major cities to 9 months for women in rural areas.

In the PDHS, women were asked about their desire for additional sons and daughters. Overall, 40 percent of currently married women do not want to have any more children. This figure increases rapidly depending on the number of children a woman has: from 17 percent for women with two living children, to 52 percent for women with four children, to 71 percent for women with six children. The desire to stop childbearing varies widely across cultural groupings. For example, among women with four living children, the percentage who want no more varies from 47 percent for women with no education to 84 percent for those with at least some secondary education.

Gender preference continues to be widespread in Pakistan. Among currently married non-pregnant women who want another child, 49 percent would prefer to have a boy and only 5 percent would prefer a girl, while 46 percent say it would make no difference.

The need for family planning services, as measured in the PDHS, takes into account women's statements concerning recent and future intended childbearing and their use of contraceptives. It is estimated that 25 percent of currently married women have a need for family planning to stop childbearing and an additional 12 percent are in need of family planning for spacing children. Thus, the total need for family planning equals 37 percent, while only 12 percent of women are currently using contraception. The result is an unmet need for family planning services consisting of 25 percent of currently married women. This gap presents both an opportunity and a challenge to the Population Welfare Programme.

Nearly one-tenth of children in Pakistan die before reaching their first birthday. The infant mortality rate during the six years preceding the survey is estimaled to be 91 per thousand live births; the under-five mortality rate is 117 per thousand. The under-five mortality rates vary from 92 per thousand for major cities to 132 for rural areas; and from 50 per thousand for women with at least some secondary education to 128 for those with no education.

The level of infant mortality is influenced by biological factors such as mother's age at birth, birth order and, most importantly, the length of the preceding birth interval. Children born less than two years after their next oldest sibling are subject to an infant mortality rate of 133 per thousand, compared to 65 for those spaced two to three years apart, and 30 for those born at least four years after their older brother or sister.

One of the priorities of the Government of Pakistan is to provide medical care during pregnancy and at the time of delivery, both of which are essential for infant and child survival and safe motherhood. Looking at children born in the five years preceding the survey, antenatal care was received during pregnancy for only 30 percent of these births. In rural areas, only 17 percent of births benefited from antenatal care, compared to 71 percent in major cities. Educational differentials in antenatal care are also striking: 22 percent of births of mothers with no education received antenatal care, compared to 85 percent of births of mothers with at least some secondary education.

Tetanus, a major cause of neonatal death in Pakistan, can be prevented by immunisation of the mother during pregnancy. For 30 percent of all births in the five years prior to the survey, the mother received a tetanus toxoid vaccination. The differentials are about the same as those for antenatal care generally.

Eighty-five percent of the births occurring during the five years preceding the survey were delivered at home. Sixty-nine percent of all births were attended by traditional or trained birth attendants, while 19 percent were assisted by a doctor or nurse.

The Expanded Programme on Immunisatlon in Pakistan has met with considerable success. Among children 12 to 23 months of age, 70 percent had received a BCG vaccination, 50 percent a measles vacci- nation, and 43 percent had received all three doses of DPT and polio vaccine. Only 35 percent, however, had received all of the recommended vaccinations, while 28 percent had received none at all. Thirty-nine percent of boys were fully protected, compared to 31 percent of girls.

Sixteen percent of children under the age of five had been ill with a cough accompanied by rapid breathing during the two weeks preceding the survey. Children 6-11 months old were most prone to acute respiratory infections (23 percent). Two-thirds (66 percent) of children who were sick were taken to a health facility or provider. All but 15 percent of the sick children received some kind of treatment.

About the same proportion of children (15 percent) had suffered from diarrhoea in the two weeks preceding the survey, with the highest incidence among children under two years of age. Nearly half (48 percent) were taken to a health facility or provider. About two of five (39 percent) children with diarrhoea were treated with oral rehydration solution prepared from ORS packets. Knowledge of oral rehydration therapy is widespread: 90 percent of mothers recognise ORS packets. Nearly two-thirds (63 percent) of mothers have used ORS packets at some time, and among these, three-quarters had mixed the solution correctly the last time they prepared it.

Thirty percent of children had suffered from fever in the two weeks preceding the survey. Those most prone to illness were age 6 to 11 months. Two-thirds of children with fever were taken to a health facility or provider.

Inadequate nutrition continues to be a serious problem in Pakistan. Fifty percent of children under five years of age suffer from stunting (an indicator of chronic undemutrition), as measured by height for age. The prevalence of stunting increases with age, from 16 percent for children under 6 months to 63 percent of four-year olds. The lowest prevalence is found in Punjab (44 percent), and the highest in Balochistan (71 percent). The mother's level of education is an important factor; the prevalence of stunting varies from 18 percent for mothers with some secondary education to 56 percent for mothers with no education.

Acute undemutrition, low weight for height, is less of a problem in Pakistan than chronic undemutrition. Nine percent of children suffer from acute undemutrition (wasting). The prevalence of wasting does not vary substantially between geographic groupings. The largest differential is for mother's education: 4 percent of children of mothers with some secondary school or higher education are wasted, compared to 10 percent of children of mothers with no schooling.

A systematic subsample of households in the women's survey was selected to obtain information from the husbands of currently married women. The focus was on obtaining information about attitudes, behaviour, and the role of husbands regarding family planning. Husbands' responses concerning knowledge and use of contraception were remarkably similar to women's responses: about four-fifths knew of at least one method, two-thirds knew of a source of supply, one-fourth reported that they and their spouses had used contraception sometime in the past, and about one-seventh were current users.

Although a majority of husbands (56 percent) approve of family planning, wives are more likely to favour family planning than their husbands. Since husbands usually have a predominant role in family decision making, the family planning programme should increase efforts to educate and motivate husbands.