The 2000 Malawi Demographic and Health Survey (MDHS) is a nationally representative sample survey covering 14,213 households, 13,220 women age 15-49, and 3,092 men age 15-54. The 2000 MDHS is similar, but much expanded in size and scope, to the 1992 MDHS. The survey was designed to provide information on fertility trends, family planning knowledge and use, early childhood mortality, various indicators of maternal and child health and nutrition, HIV/AIDS, adult and maternal mortality, and malaria control programme indicators. Unlike earlier surveys in Malawi, the 2000 MDHS sample was sufficiently large to allow for estimates of certain indicators to be produced for 11 districts in addition to estimates for national, regional, and urban-rural domains. Twenty-two mobile survey teams, trained and supervised by the National Statistical Office, conducted the survey from July to November 2000.
The principal aim of the 2000 MDHS project is to provide up-to-date information on fertility and childhood mortality levels, nuptiality, fertility preferences, awareness and use of family planning methods, use of maternal and child health services, and knowledge and behaviours related to HIV/AIDS and other sexually transmitted infections. It was designed as a follow-on to the 1992 MDHS survey, a national-level survey of similar scope. The 2000 MDHS survey also strived to collect data that would be comparable to those collected under the international Multiple Indicator Cluster Survey (MICS), sponsored by UNICEF.
In broad terms, the 2000 MDHS survey aimed to :
- Assess trends in Malawi's demographic indicators-principally, fertility and mortality
- Assist in the evaluation of Malawi's health, population, and nutrition programmes
- Advance survey methodology in Malawi and contribute to national and international databases. In more specific terms, the 2000 MDHS survey was designed to provide data on the family planning and fertility behaviour of the Malawian population and to thereby enable policymakers to evaluate and enhance family planning initiatives in the country.
- Measure changes in fertility and contraceptive prevalence and at the same time, study the factors that affect these changes, such as marriage patterns, desire for children, availability of contraception, breastfeeding habits, and important social and economic factors.
- Examine basic indicators of maternal and child health and welfare in Malawi, including nutritional status, use of antenatal and maternity services, treatment of recent episodes of childhood illness, and use of immunisation services. A particular emphasis was placed on the area of malaria programmes, including prevention activities and treatment of episodes of fever.
- Describe levels and patterns of knowledge and behaviour related to the prevention of HIV/AIDS and other sexually transmitted infections.
- Measure the level of adult and maternal mortality at the national level.
- Assess the status of women in the country.
SUMMARY OF FINDINGS
- FERTILITY Fertility Decline. The 2000 MDHS data indicate that there has been a modest decline in fertility since the 1992 MDHS. Large Fertility Differentials. Fertility levels remain high in Malawi, especially in rural parts of the country. The total fertility rate among rural women is 6.7 births per woman compared with 4.5 births in urban areas. Childbearing at Young Ages. One-third of adolescent females (age 15-19) have either already had a child or are currently pregnant.
- FAMILY PLANNING Increasing Use of Contraception. A principle cause of the fertility decline in Malawi is the steady increase in contraceptive use over the last decade.
Changing Method Mix. Currently, the most widely used methods among married women are injectable contraceptives (16 percent), female sterilisation (5 percent), and the pill (3 percent). Source of Family Planning Methods. The survey results show that government-run facilities remain the major source for contraceptives in Malawi-providing family planning methods to 68 percent of the current users.
- CHILD HEALTH AND SURVIVAL Progress in Reducing Early Childhood Mortality. The 2000 MDHS data indicate that mortality of children under age 5 has declined since the early 1990s.
Childhood Vaccination Coverage Declines. The 2000 MDHS results show that 70 percent of children age 12-23 months are fully vaccinated.
Improved Breastfeeding Practices. The 2000 MDHS results show that exclusive breast-feeding of children under 4 months of age has increased to 63 percent from only 3 percent in the 1992 MDHS. Nutritional Status of Children. The results show no appreciable change in the nutritional status of children in Malawi since 1992; still, nearly half (49 percent) of the children under age five are chronically malnourished or stunted in their growth.
- MALARIA CONTROL PROGRAMME INDICATORS Bednets. The use of insecticide-treated bednets (mosquito nets) is a primary health intervention proven to reduce malaria transmission.
Treatment of Fever in Children Under Age Five. The survey found that 42 percent of children under age five had a fever in the two weeks preceding the survey.
- WOMEN'S HEALTH Maternal Health Care. The survey findings indicate that use of antenatal services remains high in Malawi. Constraints to Use of Health Services. Women in the 2000 MDHS were asked whether certain circumstances constrain their access to and use of health services for themselves.
Rising Maternal Mortality. The survey collected data allowing measurement of maternal mortality. For the period 1994-2000, the maternal mortality ratio was estimated at 1,120 maternal deaths per 100,000 live births. This represents a rise from 620 maternal deaths per 100,000 estimated from the 1992 MDHS for the period 1986-1992.
- HIV/AIDS Impact of the Epidemic on Adult Mortality. All-cause mortality has risen by 76 percent among men and 74 percent among women age 15-49 during the 1990s. The age patterns of the increase are consistent with causes related to HIV/AIDS.
Improved Knowledge of AIDS Prevention Methods. The 2000 MDHS results indicate that practical AIDS prevention knowledge has improved since the 1996 MKAPH survey.
Condom Use. One of the main objectives of the National AIDS Control Programme is to encourage consistent and correct use of condoms, especially in high-risk sexual encounters. The
HIV-testing Experience. The 2000 MDHS data show that 9 percent of women and 15 percent of men have been tested for HIV. However, more than 70 percent of both men and women, while not yet tested, said that they would like to be tested.
Kind of Data
Sample survey data
Unit of Analysis
- Women age 15-49
- Men age 15-54
The Malawi Demographic and Health Survey 2000 covers the following topics:
- Child Labor
- GPS/Georeferenced–Global Positioning System or Georeferenced Data
- HIV Behavior
- HIV Knowledge–Questions assess knowledge/sources of knowledge/ways to avoid HIV
- Iodine salt test
- Malaria/Bednet Questions
- Maternal Mortality
- Men's Survey
- Vitamin A Questions
- Women's Status–Questions: women's autonomy (household decisionmaking/free movement/access money) & Dom. violence
The population covered by the 2000 MDHS is defined as the universe of all women age 15-49 in malawi and all men age 15-54 living in the household.
Producers and sponsors
Malawi. National Statistical Office (NSO)
United States Agency for International Development
Department for International Development
United Nations Children’s Fund
A major objective of the 2000 MDHS sample design was to provide independent estimates with acceptable precision for important population and health indicators. The sample was designed to provide these estimates for different domains, including estimates for the country, for urban and rural areas, for each of the three regions, and for eleven selected districts (each as a separate domain). The selected districts were chosen based on the size of the district (the five largest) and for programmatic importance.
The population covered by the 2000 MDHS was all women age 15-49 living in the selected households. The initial target sample was 14,000 completed eligible women interviews, and the final sample was 13,220 completed interviews. Information on sampling errors for five selected variables from the MDHS 1992 was used to help determine the most efficient allocation of the target number of interviews by domain with a minimum allocation of 900 for each of the 11 district domain. Based on this objective and some adjustments to ensure that the sample size requirements for each domain were met, the target number of completed interviews was distributed by districts.
Based on the 1998 census frame, the National Statistical Office developed an updated preliminary master sample to use during the intercensal period. In order to maintain an integrated household survey approach for future household surveys, it was decided that the 2000 MDHS sample should use the preliminary master sample as the sample frame. The 2000 MDHS sample of enumeration areas (EAs) is thus a sub-sample of NSO's preliminary master sample. NSO's preliminary master sample of EAs is stratified according to district designation and, within districts, by urban-rural designation.1 Since one objective of the master sample is to permit estimation at the district level, the total number of EAs per district was not allocated proportional to population size of the district. Instead, a minimum of 24 EAs were allocated to each district, with certain districts being allocated more EAs based on size and programmatic interest. For instance, Lilongwe and Blantyre districts were each allocated 48 EAs in the master sample. The master sample includes a total of 816 EAs out of the 9,213 EAs established in the 1998 census. A small number of EAs located in national parks and forest areas (representing less than 1 percent of the population of Malawi) were excluded from the master sample.
The design features and stratification of the master sample are implicit in the 2000 MDHS and all other subsamples.
Based on the 2000 MDHS sample design objectives of 36 EAs per "emphasis" district and adequate urban and rural representation, a total of 560 EAs were selected from the master sample: 489 in rural and 71 in urban areas. All districts are represented in the sample, but the sample is specifically designed to allow for estimation of certain parameters for the following "oversampled" districts: Lilongwe, Blantyre, Karonga, Mzimba, Kasungu, Salima, Mangochi, Machinga, Zomba, Thyolo, and Mulanje. A simple systematic sample of EAs was implemented district by district; Before the final household selection, a complete household listing operation was completed for each selected EA. Based on these household lists, the household selection was then implemented to maintain a self-weighted sample in each domain but the sampling rates differ between districts. Therefore, the total 2000 MDHS sample is weighted, and a final weighting adjustment is required to provide national estimates.
All women age 15-49 were targeted for interview in the selected households. Every fourth household was identified for inclusion in the male survey; in those households, all men age 15-54 were identified and considered eligible for individual interview.
A total of 15,421 households were selected in the MDHS sample, of which 14,352 were occupied. Of the occupied households, 14,213 were interviewed, yielding a household response rate of 99 percent. The household response rate was slightly higher in rural areas.
Within the interviewed households, 13,538 eligible women age 15-49 were identified, of which 13,220 were interviewed. The individual women's response rate to the 2000 MDHS survey was 98 percent. In the one-in-four subsample of households, 3,377 men age 15-54 were identified, of which 3,092 men were interviewed, giving a response rate of 92 percent. The main reason for nonresponse among both eligible men and women was the failure to find them at home despite repeated visits to the household. It is typical for male response rates to be lower than female response rates because men are more frequently absent from the household. Response rates for women were not influenced by urban-rural residence, but men's response rates were significantly better in rural areas than in urban areas.
In comparing response rates from the 1992 MDHS survey and the 2000 MDHS survey, the more recent survey performed slightly better. The women's response rate rose from 97 to 98 percent, and the men's response rate increased from 89 to 92 percent.
Dates of Data Collection
Data Collection Mode
Data Collection Notes
Training of field staff for the main survey was conducted over a three-week period in June and July 2000. The training took place at Chilema Ecumenical Lay Training Centre outside Zomba Municipality. A total of 200 field staff were trained.
The training course consisted of instruction in general interviewing techniques, and field procedures, a detailed review of items on the questionnaires, instruction and practice in weighing and measuring children and women, mock interviews between participants, and practical interviews in surrounding villages. In-depth discussions of the translations were an important part of the training programme. The trainees included 26 medically trained personnel who worked on the survey as health technicians. Of the trainees, 183 who performed satisfactorily in the training programme were selected to form the 22 teams for the fieldwork. The rest, if qualified, were employed as MDHS data entry and registry staff.
Twenty-two interviewing teams carried out the fieldwork for the MDHS survey, with each team consisting of one team leader, one field editor, four female interviewers, one health technician, one male interviewer, and one driver. On a few teams, an additional male interviewer was added. Additionally, six senior staff from NSO coordinated and supervised field activities. Data collection began on July 12 and was completed in early November 2000.
National Statistical Office (NSO)
The questionnaire for each DHS can be found as an appendix in the final report for each study.
Three types of questionnaires were used in the 2000 MDHS survey: a) the Household Questionnaire, b) the Women's Questionnaire, and c) the Men's Questionnaire. The contents of the questionnaires were based on the MEASURE DHS+ model. A series of meetings were held with policy experts, programme managers, and other professionals in Malawi to review, adapt, and revise the questionnaires. This process culminated in English-version questionnaires that were then translated into Chichewa and Tumbuka.
a) The Household Questionnaire was used to list all of the usual members and visitors in the selected households1. Basic information on each person listed was collected, including age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify all of the eligible women (age 15-49) and men (age 15-54) for individual interviews. In addition, information was collected about characteristics of the household, such as the source of water, type of toilet facilities, materials used to construct the household's dwelling, and ownership of various consumer goods. Data on child labour practises, use of bednets (mosquito nets), and nutritional status of children and women were also collected in the Household Questionnaire.
b) The Women's Questionnaire was used to collect information from women age 15-49 and included questions on the following topics:
- Background characteristics (age, education, religion, etc.)
- Reproductive history (to arrive at fertility and childhood mortality rates)
- Knowledge and use of family planning methods
- Antenatal and delivery care
- Infant feeding practises, including patterns of breastfeeding
- Childhood vaccinations
- Recent episodes of childhood illness and responses to illness, especially recent fevers
- Marriage and sexual activity
- Fertility preferences
- Woman's status and decisionmaking
- Mortality of adults, including maternal mortality
- AIDS-related knowledge, attitudes, and behaviour
c) The Men's Questionnaire covered many of the same topics but excluded the detailed reproductive history and sections dealing with maternal and child health and adult and maternal mortality. The Men's questionnaire is consequently much shorter than the Women's Questionnaire.
The questionnaires were pretested in February 2000 in Mzimba, Ntcheu, and Blantyre City. More than 200 interviews were conducted over a one-week period. The questionnaires were produced in three language versions: Chichewa, Tumbuka, and English. However, interviews could be conducted in any of the languages spoken in Malawi if the respondent was not fluent in one of these three languages. Adjustments in language and content were made to the questionnaires based on the lessons drawn from the pretest interviews.
Complete, field-edited questionnaires were brought to the NSO headquarters in Zomba after collection during supervisory visits by NSO senior staff. Data entry began one week after data collection started and was completed in December 2000. Office editing, coding of open-ended questions, and editing based on computer identified inconsistencies in the data continued into January 2001. The questionnaires were entered, verified, and edited using a new version of ISSA (Integrated System for Survey Analysis) adapted by ORC Macro and the U.S. Bureau of Census for integrated use in censuses and surveys.
Estimates of Sampling Error
Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2000 MDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results.
A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design.
If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2000 MDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the 2000 MDHS is the ISSA Sampling Error Module (ISSAS). This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jacknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates.
The Jacknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one clusters in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2000 MDHS, there were 559 non-empty clusters (one cluster contained no eligible women). Hence, 559 replications were created.
In addition to the standard error, ISSAS computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. ISSAS also computes the relative error and confidence limits for the estimates.
Sampling errors for the 2000 MDHS are calculated for selected variables considered to be of primary interest. The results are presented in an appendix of the Final Report for the country as a whole, for urban and rural areas, for north, central and south regions, and for each of 11 over-sampled district plus the rest of the country. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1 of the Final Report. Tables B.2 to B.18 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1).
In general, the relative standard error for most estimates for the country as a whole is small, except for estimates of very small proportions. There are some differentials in the relative standard error for the estimates of sub-populations. For example, for the variable contraceptive use among currently married women age 15-49, the relative standard errors as a percent of the estimated mean for the whole country, for urban areas, and for rural areas are 2.2 percent, 4.7 percent, and 2.3 percent, respectively.
The confidence interval (e.g., as calculated for contraceptive use among currently married women age 15-49) can be interpreted as follows: the overall national sample proportion is 0.306 and its standard error is 0.007. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e. 0.306±2(0.007). There is a high probability (95 percent) that the true average proportion of contraceptive use among currently married women age 15 to 49 is between 0.293 and 0.320.
Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2000 MDHS to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically.
Data and Data Related Resources
Demography and Social Statistics Division, National Statistical Office
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