Nepal Demographic and Health Survey 2011 Demographic and Health Survey Nepal 2011 Nepal Demographic and Health Survey 2011 Population Division Ministry of Health and Population Government of Nepal Kathmandu, Nepal New ERA Kathmandu, Nepal ICF International Calverton, Maryland, U.S.A. March 2012 New ERA Ministry of Health and Population The 2011 Nepal Demographic and Health Survey (2011 NDHS) was implemented by New ERA under the aegis of the Ministry of Health and Population (MOHP). Funding for the survey was provided by USAID. ICF International provided technical assistance for the survey through the MEASURE DHS program, a USAID- funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development. Additional information about the survey may be obtained from the Population Division, Ministry of Health and Population, Government of Nepal, Ramshahpath, Kathmandu, Nepal; Telephone: (977-1) 4262987; New ERA, P.O. Box 722, Kathmandu, Nepal; Telephone: (977-1) 4423176/4413603; Fax: (977-1) 4419562; E-mail: info@newera.wlink.com.np. Information about the DHS program may be obtained from MEASURE DHS, ICF International, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: reports@measuredhs.com, Internet: http://www.measuredhs.com. Recommended citation: Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland. Contents • iii CONTENTS Tables and Figures ix Foreword xv Acknowledgments xvii Technical Advisory Committee and Technical Working Committee xix Contributors to the Report xxi Millennium Development Goal Indicators xxiii Map of Nepal xxiv CHAPTER 1 INTRODUCTION 1 1.1 History, Geography, and Economy 1 1.1.1 History 1 1.1.2 Geography 1 1.1.3 Economy 3 1.2 Population 3 1.3 Population and Health Policies and Programs 4 1.4 Objectives of the Survey 5 1.5 Organization of the Survey 6 1.6 Sample Design 6 1.6.1 Sampling Frame 7 1.6.2 Domains 7 1.6.3 Sample Selection 7 1.7 Questionnaires 8 1.8 Hemoglobin Testing 8 1.9 Listing, Pretest, Training, and Fieldwork 9 1.9.1 Listing 9 1.9.2 Pretest 9 1.9.3 Training of Field Staff 9 1.9.4 Fieldwork 10 1.10 Data Processing 10 1.11 Response Rates 10 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 13 2.1 Household Characteristics 13 2.1.1 Water and Sanitation 13 2.1.2 Housing Characteristics 16 2.1.3 Household Possessions 18 2.2 Socioeconomic Status Index 19 2.3 Household Population by Age and Sex 20 2.4 Migration Status 22 2.5 Household Composition 25 2. 6 Birth Registration 25 2.7 Children’s Living Arrangements, Orphanhood, and School Attendance 26 2.8 Education of Household Population 28 2.8.1 Educational Attainment of Household Population 28 2.8.2 School Attendance Ratios 30 2.8.3 Early Childhood Development Centers 33 2.9 Possession of Mosquito Nets 34 2.10 Prevalence and Causes of Food Insecurity and Coping Strategies 35 iv • Contents CHAPTER 3 CHARACTERISTICS OF RESPONDENTS 41 3.1 Characteristics of Survey Respondents 41 3.1.1 Spousal Separation 43 3.2 Educational Attainment by Background Characteristics 44 3.3 Literacy 47 3.4 Access to Mass Media 49 3.4.1 Access to Specific Radio and Television Programs 51 3.4.2 Preferred Media Source for Health-Related Programs 53 3.5 Employment 54 3.5.1 Employment Status 54 3.5.2 Occupation 57 3.5.3 Earnings, Employers, and Continuity of Employment 60 3.6 Use of Tobacco 61 CHAPTER 4 MARRIAGE AND SEXUAL ACTIVITY 65 4.1 Current Marital Status 65 4.2 Polygyny 66 4.3 Age at First Marriage 67 4.4 Median Age at First Marriage 68 4.5 Age at First Sexual Intercourse 70 4.6 Median Age at First Sexual Intercourse 71 4.7 Recent Sexual Activity 71 CHAPTER 5 FERTILITY 75 5.1 Current Fertility 75 5.2 Fertility Differentials 76 5.3 Fertility Trends 77 5.4 Children Ever Born and Living 78 5.5 Birth Intervals 79 5.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility 81 5.7 Menopause 82 5.8 Age at First Birth 82 5.9 Teenage Pregnancy and Motherhood 83 CHAPTER 6 FERTILITY PREFERENCES 85 6. 1 Desire for More Children 85 6.2 Desire to Limit Childbearing by Background Characteristics 86 6.3 Ideal Family Size 88 6.4 Fertility Planning 90 6.5 Wanted Fertility Rates 90 CHAPTER 7 FAMILY PLANNING 93 7.1 Knowledge of Contraceptive Methods 94 7.2 Current Use of Contraception 94 7.3 Current Use of Contraception by Background Characteristics 95 7.4 Trends in Current Use of Family Planning 97 7.5 Timing of Female Sterilization 98 7.6 Source of Contraception 99 7.7 Brands of Pills and Condoms Used 100 7.8 Informed Choice 101 7.9 Contraceptive Discontinuation Rates 102 7.10 Reasons for Discontinuation of Contraceptive Use 102 Contents • v 7.11 Knowledge of Fertile Period 103 7.12 Need and Demand for Family Planning Services 103 7.13 Future Use of Contraception 105 7.14 Exposure to Family Planning Messages 105 7.15 Contact of Nonusers with Family Planning Providers 107 7.16 Counseling During Postpartum and Post-abortion 108 7.17 Men’s Attitudes towards Contraception 110 CHAPTER 8 INFANT AND CHILD MORTALITY 111 8.1 Assessment of Data Quality 112 8.2 Levels and Trends in Infant and Child Mortality 113 8.3 Socioeconomic Differentials in Childhood Mortality 114 8.4 Demographic Differentials in Mortality 115 8.5 Perinatal Mortality 116 8.6 High-risk Fertility Behavior 117 CHAPTER 9 MATERNAL HEALTH 119 9.1 Antenatal Care 119 9.1.1 Number and Timing of Antenatal Visits 121 9.2 Components of Antenatal Care 121 9.3 Tetanus Toxoid Vaccination 123 9.4 Place of Delivery 124 9.5 Assistance during Delivery 126 9.5.1 Care and Support during Delivery 128 9.5.2 Birth Preparedness 130 9.6 Postnatal Care 130 9.6.1 Timing of First Postnatal Checkup for the Mother 131 9.6.2 Provider of First Postnatal Checkup for Mother 132 9.7 Newborn Care 132 9.7.1 Provider of First Postnatal Checkup for the Newborn 134 9.7.2 Newborn Care Practices 135 9.8 Abortion 136 9.8.1 Knowledge that Abortion is Legal in Nepal 137 9.8.2 Knowledge about Places That Provide Safe Abortions 138 9.8.3 Pregnancy Outcomes 139 9.8.4 Reason for the Most Recent Abortion 140 9.8.5 Type of Abortion Procedure 141 9.8.6 Place and Provider for Abortion 142 9.8.7 Complications during and after Abortion and Contraception 143 9.8.8 Abortion and Post-abortion Cost 143 9.9 Uterine Prolapse 143 9.10 Problems in Accessing Health Care 143 9.10.1 Awareness and Practice of Health Services in the Government Sector 144 CHAPTER 10 CHILD HEALTH 147 10.1 Child’s Weight and Size at Birth 148 10.2 Vaccination Coverage 149 10.3 Vaccination by Background Characteristics 150 10.4 Trends in Immunization Coverage 152 10.5 Acute Respiratory Infection 152 10.6 Fever 153 10.7 Diarrhea 155 vi • Contents 10.8 Diarrhea Treatment 156 10.9 Feeding Practices during Diarrhea 158 10.10 Knowledge of ORS Packets 159 10.11 Disposal of Children’s Stools 160 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN 163 11.1 Nutritional Status of Children 164 11.1.1 Measurement of Nutritional Status among Young Children 164 11.1.2 Data Collection 165 11.1.3 Measures of Child Nutrition Status 165 11.1.4 Trends in Children’s Nutritional Status 168 11.2 Breastfeeding and Complementary Feeding 169 11.2.1 Initiation of Breastfeeding 169 11.3 Breastfeeding Status by Age 171 11.4 Duration of Breastfeeding 173 11.5 Types of Complementary Foods 174 11.6 Infant and Young Child Feeding (IYCF) Practices 175 11.7 Prevalence of Anemia in Children 177 11.8 Micronutrient Intake among Children 179 11.9 Nutritional Status of Women 182 11.10 Prevalence of Anemia in Women 184 11.11 Micronutrient Intake among Mothers 185 CHAPTER 12 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 189 12.1 Introduction 189 12.2 HIV and AIDS Knowledge, Transmission, and Prevention Methods 190 12.2.1 Knowledge of AIDS 190 12.2.2 Knowledge of HIV Prevention Methods 191 12.2.3 Comprehensive Knowledge of HIV and AIDS Transmission 193 12.3 Knowledge of Prevention of Mother-to-Child Transmission of HIV 196 12.4 Accepting Attitudes toward those Living with HIV and AIDS 197 12.5 Attitudes toward Negotiating Safer Sex 199 12.6 Multiple Sexual Partners 201 12.7 Paym ent for Sex 202 12.8 Testing for HIV 203 12.9 Self-reporting of Sexually Transmitted Infections 206 12.10 Prevalence of Medical Injections 207 12.11 HIV and AIDS-related Knowledge and Behavior among Youth 208 12.11.1 Knowledge about HIV and AIDS and of Sources for Condoms 209 12.11.2 Age at First Sexual Intercourse among Youth 210 12.11.3 Premarital Sex 211 12.11.4 Multiple Sexual Partners among Youth 212 12.11.5 Age Mixing in Sexual Relationships among Women Age 15-19 213 12.11.6 Recent HIV Tests among Youth 214 CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 215 13.1 Employment and Form of Earnings 216 13.2 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s and Their Husbands’ Earnings 218 13.3 Control over Husbands’ Earnings 219 13.4 Women’s and Men’s Ownership of Selected Assets 222 Contents • vii 13.5 Women’s Participation in Decision-making 224 13.6 Women’s Empowerment Indicators 227 13.7 Current Use of Contraception by Women’s Status 229 13.8 Ideal Family Size and Unmet Need by Women’s Status 230 13.9 Reproductive Health Care and Women’s Empowerment 231 13.10 Infant and Child Mortality and Women’s Empowerment 232 CHAPTER 14 DOMESTIC VIOLENCE 233 14.1 Measurement of Violence 234 14.1.1 Use of Valid Measures of Violence 234 14.1.2 Ethical Considerations in the 2011 NDHS 235 14.1.3 Subsample for the Violence Module 235 14.2 Experience of Physical Violence 236 14.3 Perpetrators of Physical Violence 237 14.4 Experience of Sexual Violence 237 14.5 Perpetrators of Sexual Violence 238 14.6 Experience of Different Forms of Violence 239 14.7 Forced at Sexual Initiation 239 14.8 Violence during Pregnancy 239 14.9 Marital Control by Husband 240 14.10 Forms of Spousal Violence 241 14.11 Spousal Violence by Background Characteristics 243 14.12 Violence by Spousal Characteristics and Women’s Empowerment Indicators 244 14.13 Frequency of Spousal Violence 245 14.14 Onset of Spousal Violence 247 14.15 Physical Consequences of Spousal Violence 247 14.16 Violence by Women against Their Husbands 248 14.17 Help-seeking Behavior by Women Who Experience Violence 250 REFERENCES 253 APPENDIX A SAMPLE DESIGN AND IMPLEMENTATION 261 APPENDIX B ESTIMATES OF SAMPLING ERRORS 267 APPENDIX C DATA QUALITY TABLES 281 APPENDIX D PERSONS INVOLVED IN THE 2011 NEPAL DEMOGRAPHIC AND HEALTH SURVEY 287 APPENDIX E QUESTIONNAIRES 291 Tables and Figures • ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators 3 Table 1.2 Results of the household and individual interviews 11 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION Table 2.1 Household drinking water 14 Table 2.2 Household sanitation facilities 15 Table 2.3 Hand washing 16 Table 2.4 Household characteristics 17 Table 2.5 Household possessions 18 Table 2.6 Wealth quintiles 20 Table 2.7 Household population by age, sex, and residence 21 Table 2.8 Migration status 22 Table 2.9.1 Migration status: Men 23 Table 2.9.2 Migration status: Women 24 Table 2.10 Household composition 25 Table 2.11 Birth registration of children under age five 26 Table 2.12 Children’s living arrangements and orphanhood 27 Table 2.13.1 Educational attainment of the female household population 29 Table 2.13.2 Educational attainment of the male household population 30 Table 2.14.1 School attendance ratios: Primary school 31 Table 2.14.2 School attendance ratios: Secondary school 32 Table 2.15 Children enrolled in school-based pre-primary classes and Early Childhood Development centers 34 Table 2.16 Possession of mosquito nets 35 Table 2.17 Household food security 37 Table 2.18 Coping strategies of households with food insecurity 38 Table 2.19 Causes of household food insecurity 39 Figure 2.1 Population Pyramid 21 Figure 2.2 Age-specific Attendance Rates of the de facto Population 5 to 24 Years 33 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3. 1 Background characteristics of respondents 42 Table 3.2 Spousal separation 44 Table 3.3.1 Educational attainment: Women 45 Table 3.3.2 Educational attainment: Men 46 Table 3.4.1 Literacy: Women 47 Table 3.4.2 Literacy: Men 48 Table 3.5.1 Exposure to mass media: Women 49 Table 3.5.2 Exposure to mass media: Men 50 Table 3.6.1 Exposure to specific health programs on radio and television: Women 51 Table 3.6.2 Exposure to specific health programs on radio and television: Men 52 Table 3.7.1 Preferred media source for health-related information: Women 53 Table 3.7.2 Preferred media source for health-related information: Men 54 Table 3.8.1 Employment status: Women 55 Table 3.8.2 Employment status: Men 57 [...]... 286 xiv • Tables and Figures FOREWORD The 2011 Nepal Demographic and Health Survey is the fourth nationally representative comprehensive survey conducted as part of the worldwide Demographic and Health Surveys (DHS) project in the country The survey was implemented by New ERA under the aegis of the Population Division, Ministry of Health and Population Technical support for this survey was provided... Ministry of Health and Population Chief, Administrative Division, Ministry of Health and Population Chief, HR and Financial Resource Management Division, Ministry of Health and Population Director, Family Health Division, Department of Health Services Director, Child Health Division, Department of Health Services Director, NCASC, Ministry of Health and Population Director, NHIECC, Ministry of Health and Population... countries and therefore affords national and international comparisons The first Demographic and Health Survey (DHS) in Nepal was the 1996 Nepal Family Health Survey (NFHS), conducted as part of the worldwide DHS program; subsequently, surveys have been conducted every five years, in 2001, 2006, and now in 2011 Wherever possible, the 2011 NDHS data are compared with data from the earlier DHS surveys in Nepal, ... Mr Ajit Singh Pradhan, Nepal Health Sector Support Program Mr Ashoke Shrestha, Nepal Family Health Program Dr Rajendra Bhadra, Nepal Family Health Program Mr Bharat Ban, Nepal Family Health Program Mr Dirgha Raj Shrestha, Nepal Family Health Program Mr Deepak Paudel (USAID) Dr Amit Bhandari, DFID Ms Iva Schildbach (GIZ) Mr Manav Bhattarai, World Bank Mr Satish Raj Pandey, Family Health International... the survey as chiefs of the Population Division, Ministry of Health and Population We would like to express our heartfelt gratitude to the USAID mission in Nepal We acknowledge the technical input and support provided by Ms Anne M Peniston, Director, Office of Health and Family Planning, Ms Shanda Steimer, Director, Office of Health and Family Planning, Mr Han Kang, Deputy Director, Office of Health and. .. Marasini, Public Health Administrator, Ministry of Health and Population Mr Raj Kumar Pokharel, Public Health Administrator, CHD, Department of Health Services Mr Naresh Khatiwada, Statistical Officer/Demographer, Ministry of Health and Population Mr Anil Thapa, Demographer, Ministry of Health and Population Mr Badri Bahadur Khadka, NHIECC Chief, Demographic Section, FHD, Department of Health Services... Population Division, Ministry of Health and Population Mr Surya Prasad Acharya, Ministry of Health and Population Mr Upendra Adhikari, Ministry of Women and Social Welfare Dr Megha Raj Dhakal, Population Division, Ministry of Health and Population Mr Naresh Khatiwada, Population Division, Ministry of Health and Population Mr Anil Thapa, Population Division, Ministry of Health and Population Ms Lila Kumari... Department of Health Services, Ministry of Health and Population Dr Shyam Raj Uprety, Child Health Division, Department of Health Services Dr Ramesh Kharel, National Center for AIDS and STD Control Dr B.R Marasini, Ministry of Health and Population Dr Kedar Baral (PAHS) Dr R.K Adhikari, KIST Medical College Dr Prakash Dev Pant, Family Health International 360 Dr Suresh Tiwari, Nepal Health Sector Support... population and health surveys The survey includes topics on fertility levels and determinants, family planning, fertility preferences, childhood mortality, children and women’s nutritional status, the utilization of maternal and child health services, knowledge of HIV/AIDS and STIs, women’s empowerment and for the first time, information on women facing different types of domestic violence The survey also... family planning services, and maternal, newborn, and child health services in a manner that builds local capacity and engages stakeholders (Johns Hopkins University Center for Communication Programs, 2011; USAID /Nepal, 2010) The Nepal Health Sector Program Implementation Plan (NHSP-IP 2004-2009) was launched by the Ministry of Health and Population to improve the health status of the Nepalese population . Nepal Demographic and Health Survey 2011 Demographic and Health Survey Nepal 2011 Nepal Demographic and Health Survey 2011 . Ministry of Health and Population (MOHP) [Nepal] , New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry