Demographic and Health Survey 1989-1990

The Sudan Demographic and Health Survey (SDHS) was conducted in two phases between November 15, 1989 and May 21, 1990 by the Department of Statistics of the Ministry of Economic and National Planning. The survey collected information on fertility levels, marriage patterns, reproductive intentions, knowledge and use of contraception, maternal and child health, maternal mortality, and female circumcision. The survey findings provide the National Population Committee and the Ministry of Health with valuable information for use in evaluating population policy and planning public health programmes.

A total of 5860 ever-married women age 15-49 were interviewed in six regions in northern Sudan; three regions in southern Sudan could not be included in the survey because of civil unrest in that part of the country. The SDHS provides data on fertility and mortality comparable to the 1978-79 Sudan Fertility Survey (SFS) and complements the information collected in the 1983 census.

The primary objective of the SDHS was to provide data on fertility, nuptiality, family planning, fertility preferences, childhood mortality, indicators of maternal health care, and utilization of child health services. Additional information was coUected on educational level, literacy, source of household water, and other housing conditions.

The SDHS is intended to serve as a source of demographic data for comparison with the 1983 census and the Sudan Fertility Survey (SFS) 1978-79, and to provide population and health data for policymakers and researchers. The objectives of the survey are to:

• assess the overall demographic situation in Sudan,
• assist in the evaluation of population and health programmes,
• assist the Department of Statistics in strengthening and improving its technical skills for conducting demographic and health surveys,
• enable the National Population Committee (NPC) to develop a population policy for the country, and
• measure changes in fertility and contraceptive prevalence, and study the factors which affect these changes, and
• examine the basic indicators of maternal and child health in Sudan.

MAIN RESULTS

Fertility levels and trends

Fertility has declined sharply in Sudan, from an average of six children per women in the Sudan Fertility Survey (TFR 6.0) to five children in the Sudan DHS survey flTR 5.0). Women living in urban areas have lower fertility (TFR 4.1) than those in rural areas (5.6), and fertility is lower in the Khartoum and Northern regions than in other regions. The difference in fertility by education is particularly striking; at current rates, women who have attained secondary school education will have an average of 3.3 children compared with 5.9 children for women with no education, a difference of almost three children.

Although fertility in Sudan is low compared with most sub-Saharan countries, the desire for children is strong. One in three currently married women wants to have another child within two years and the same proportion want another child in two or more years; only one in four married women wants to stop childbearing. The proportion of women who want no more children increases with family size and age. The average ideal family size, 5.9 children, exceeds the total fertility rate (5.0) by approximately one child. Older women are more likely to want large families than younger women, and women just beginning their families say they want to have about five children.

Marriage

Almost all Sudanese women marry during their lifetime. At the time of the survey, 55 percent of women 15-49 were currently married and 5 percent were widowed or divorced. Nearly one in five currently married women lives in a polygynous union (i.e., is married to a man who has more than one wife). The prevalence of polygyny is about the same in the SDHS as it was in the Sudan Fertility Survey.

Marriage occurs at a fairly young age, although there is a trend toward later marriage among younger women (especially those with junior secondary or higher level of schooling). The proportion of women 15-49 who have never married is 12 percentage points higher in the SDHS than in the Sudan Fertiliy Survey.

There has been a substantial increase in the average age at first marriage in Sudan. Among SDHS. Since age at first marriage is closely associated with fertility, it is likely that fertility will decrease in the future. With marriages occurring later, women am having their first birth at a later age. While one in three women age 45-49 had her first birth before age 18, only one in six women age 20-24 began childbearing prior to age 18. The women most likely to postpone marriage and childbearing are those who live in urban areas ur in the Khartoum and Northern regions, and women with pest-primary education.

Breastfeeding and postpartum abstinence

Breastfeeding and postpartum abstinence provide substantial protection from pregnancy after the birth uf a child. In addition to the health benefits to the child, breastfeeding prolongs the length of postpartum amenorrhea. In Sudan, almost all women breastfeed their children; 93 percent of children are still being breastfed 10-11 months after birth, and 41 percent continue breastfeeding for 20-21 months. Postpartum abstinence is traditional in Sudan and in the first two months following the birth of a child 90 percent of women were abstaining; this decreases to 32 percent after two months, and to 5 percent at~er one year. The survey results indicate that the combined effects of breastfeeding and postpartum abstinence protect women from pregnancy for an average of 15 months after the birth of a child.

Knowledge and use of contraception

Most currently married women (71 percent) know at least one method of family planning, and 59 percent know a source for a method. The pill (70 percent) is the most widely known method, followed by injection, female sterilisation, and the IUD. Only 39 percent of women knew a traditional method of family planning.

Despite widespread knowledge of family planning, only about one-fourth of ever-married women have ever used a contraceptive method, and among currently married women, only 9 percent were using a method at the time of the survey (6 percent modem methods and 3 percent traditional methods). The level of contraceptive use while still low, has increased from less than 5 percent reported in the Sudan Fertility Survey.

Use of family planning varies by age, residence, and level of education. Current use is less than 4 percent among women 15-19, increases to 10 percent for women 30-44, then decreases to 6 percent for women 45-49. Seventeen percent of urban women practice family planning compared with only 4 percent of rural women; and women with senior secondary education are more likely to practice family planning (26 percent) than women with no education (3 percent).

There is widespread approval of family planning in Sudan. Almost two-thirds of currently married women who know a family planning method approve of the use of contraception. Husbands generally share their wives's views on family planning. Three-fourths of married women who were not using a contraceptive method at the time of the survey said they did not intend to use a method in the future.

Communication between husbands and wives is important for successful family planning. Less than half of currently married women who know a contraceptive method said they had talked about family planning with their husbands in the year before the survey; one in four women discussed it once or twice; and one in five discussed it more than twice. Younger women and older women were less likely to discuss family planning than those age 20 to 39.

Mortality among children

The neonatal mortality rate in Sudan remained virtually unchanged in the decade between the SDHS and the SFS (44 deaths per 1000 births), but under-five mortality decreased by 14 percent (from 143 deaths per 1000 births to 123 per thousand). Under-five mortality is 19 percent lower in urban areas (117 per 1000 births) than in rural areas (144 per 10(30 births).

The level of mother's education and the length of the preceding birth interval play important roles in child survival. Children of mothers with no education experience nearly twice the level of under-five mortality as children whose mother had attained senior secondary or nigher education. Mortality among children under five is 2.7 times higher among children born after an interval of less than 24 months than among children born after interval of 48 months or more.

Maternal mortality

The maternal mortality rate (maternal deaths per 1000 women years of exposure) has remained nearly constant over the twenty years preceding the survey, while the maternal mortality ratio (number of maternal deaths per 100,000 births), has increased (despite declining fertility). Using the direct method of estimation, the maternal mortality ratio is 352 maternal deaths per 100,000 births for the period 1976-82, and 552 per 100,000 births for the period 1983-89. The indirect estimate for the maternal mortality ratio is 537. The latter estimate is an average of women's experience over an extended period before the survey centred on 1977.

Maternal health care

The health care mothers receive during pregnancy and delivery is important to the survival and well-being of both children and mothers. The SDHS results indicate that most women in Sudan made at least one antenatal visit to a doctor or trained health worker/midwife. Eighty-seven percent of births benefitted from professional antenatal care in urban areas compared with 62 percent in rural areas. Although the proportion of pregnant mothers seen by trained health workers/midwives are similar in urban and rural areas, doctors provided antenatal care for 42 percent and 19 percent of births in urban and rural areas, respectively.

Neonatal tetanus, a major cause of infant deaths in developing countries, can be prevented if mothers receive tetanus toxoid vaccinations. One-third of Sudanese mothers received two doses of tetanus toxoid during their pregnancy, while an additional one-tenth received one dose. The proportion of births whose mothers received two doses of tetanus toxoid is substantially higher in urban areas than in rural.

For births occurring in the five years preceding the survey, 18 percent of urban mothers were attended by doctors, 68 percent by trained health workers/midwives, and 11 percent by traditional birth attendants; for rural mothers these percentages were 4 percent, 56 percent, and 34 percent, respectively, indicating that rural women still depend on the traditional attendants more than doctors for assistance at delivery.

Sudan's Expanded Programme of Immunisation (EPI) recommends that all children receive immunisations in the first year of life against common childhood diseases. In the SDHS mothers of 46 percent of children age 12-23 months were able to show interviewers the health card documenting their child's immunisations. For 33 percent of children the health card was not available but their mothers reported that they had received at least one immunisation.

The SDHS results indicate that immunisation coverage for children 12-23 months is moderate: 76 percent of children had been immunised against BCG, 60 percent had received three doses of DPT, 61 percent had received three doses of polio, 61 percent were vaccinated against measles, and 52 percent had had all primary immunisations, lmmunisation coverage is higher for urban children than for rural children; it is higher in the Khartoum and Northern regions than in other regions; and it increases sharply with the mother's level of education.

Diarrhea, a common illness among infants and young children, can cause severe dehydration and if left untreated, can lead to death. The SDHS results show that 30 percent of children under five had had diarrhea in the two weeks preceding the survey, and 18 percent in the 24 hours preceding the survey. Prevalence was highest among children between the ages of 6 and 23 months.

Dehydration caused by diarrhea can be treated effectively and inexpensively using oral rehydration therapy (ORT). In Sudan 29 percent of children with diarrhea were treated with a solution prepared from ORS packets (salts), and 8 percent with a homemade salt and sugar solution. About half of the children with diarrhea were taken to a medical facility; however, 30 percent neither visited a health facility nor received any treatment.

Coughing together with difficult breathing is symptom of lower respiratory tract infection particularly pneumonia. Of all children under five, 48 percent had had a cough and 19 percent had had both a cough and difficult breathing during the two weeks before the survey. About 50 percent of the children suffering from cough were taken for treatment to a government health facility, 11 percent went to private doctors or hospitals and 4 percent consulted pharmacies. Children having cough in urban areas were more likely to be taken to private doctors (25 percent) than children in rural areas (3 percent).

Female circumcision

The SDHS collected data on the prevalence of female circumcision and the attitudes of women and men toward the practice. Eighty-nine percent of ever-married women in Sudan have been circumcised, representing a slight drop from 96 percent reported by the SFS. The majority of women received Pharaonic circumcision (82 percent); 15 percent received Sunna, and 3 percent had an intermediate type of circumcision.

More than three-quarters of ever-married women support continuation of the practice of female circumcision. Support for circumcising their own daughters is even stronger than for circumcision in general. Among those wanting to retain the practice, Sunna circumcision (the least severe type) is preferred by 48 percent of the ever-married women; 46 percent prefer Pharaonic circumcision and 5 percent prefer the intermediate type. Those who oppose continuation of female circumcision said they believe the best way to abolish the practice is through education campaigns and the enforcement of laws against female circumcision.