1991 Belize Family Health Survey Final Report

Publication date: 1992

1991 Belize Family Health Survey Final Report Central Statistical Office Ministry of Finance Belize Family Life Association Ministry of Health Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control May 1992 Reprinted by U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Centers for Disease Control Atlanta, Georgia 30333 May, 1992 Preface The 1991 Belize Family Health Survey was the first national sample survey designed to provide information on fertility, infant mortality, family planning, and the use of maternal and child health services in Belize. The survey was sponsored by the Belize Family Life Association (BFLA) and the Ministry of Health (MOH), in collaboration with the Breast is Best League of Belize. The implementing agency for the survey was the Central Statistical Office of the Ministry of Finance, with technical assistance from the Division of Reproductive Health, Centers for Disease Control (CDC), and funding from the United States Agency for International Development (AID). General areas covered in the survey were fertility and its determinants; attitudes towards childbearing; knowledge, use, and source of contraception, including reasons for nonuse of contraception and desire to use in the future; characteristics of women at risk of an unplanned pregnancy; use of and potential demand for surgical contraception; use of maternal and child health services; breastfeeding and weaning practices; immunization levels and the prevalence of diarrhea and acute respiratory illness among children less than 5 years of age; infant and child mortality; and knowledge of AIDS. This report summarizes the findings of the survey. It was prepared by Richard Monteith, Paul Stupp, and Beth Macke, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia 30333, U.S.A., and Sandra Paredez, Central Statistical Office, Ministry of Finance, Belmopan, Belize. Contributors We would like to acknowledge all of the people who contributed to the various phases of the survey. The performance of such an investigation involves the participation of persons too numerous to mention here. There are some, however, who have played key roles in the development and implementation of the survey. Central Statistical Office, Ministry of Finance ───────────────────────────────────────────────────────────────── Sylvan Roberts Martin Aldana Marion Palacio Belize Family Life Association ───────────────────────────────────────────────────────────────── Jewell Quallo Ministry of Health ───────────────────────────────────────────────────────────────── Ramon Figueroa USAID/Belize ───────────────────────────────────────────────────────────────── Patrick McDuffie Amelia Cadle Bibi Essama Division of Reproductive Health, Centers for Disease Control ───────────────────────────────────────────────────────────────── Leo Morris Melanie Bourne Tina Campbell Elizabeth Fitch Laura Fletcher Kenyatta Jones Renee Samara Keith West Pat Whitaker Contents Preface Contributors Contents Summary .1 1. Introduction .5 2. Survey Methodology .7 3. Fertility .11 3.1 Levels and Differentials.11 3.2 Marital Fertility .11 3.3 Retrospective Fertility.12 3.4 Nuptiality .13 3.5 Breastfeeding .14 3.6 Fertility Preferences .14 Planning Status of Last Pregnancy .14 Current Pregnancy Intentions .15 Desire for More Children .15 4. Attitudes Towards Childbearing .19 4.1 Ideal Family Size.19 4.2 Opinions About Childbearing .19 5. Knowledge, Use, and Source of Contraception .21 5.1 Knowledge of Contraceptive Methods .21 5.2 Knowledge of the Fertile Period .21 5.3 Current Contraceptive Use .22 Reasons for Currently Using Contraception.25 Characteristics at First Contraceptive Use .25 Contraception Prevalence in the Region .25 5.4 Source of Contraception .26 5.5 Reasons for Nonuse of Contraception and Desire to Use in the Future.27 Reasons for Nonuse .27 Reasons Discontinued the Use of Contraception .27 Desire to Use Contraception in the Future .28 6. Women in Need of Family Planning Services .35 7. Use of and Potential Demand for Surgical Contraception .39 7.1 Profile of Sterilized Women .39 7.2 Use of Contraception Before Sterilization .39 7.3 Satisfaction with the Decision .39 7.4 Demand for Sterilization .40 8. Use of Maternal and Child Health Services . 43 8.1 Prenatal Care. 43 8.2 Location and Type of Last Delivery . 43 8.3 Postpartum Care and Newborn Checkup . 44 8.4 Use of MCH Services . 44 9. Breastfeeding and Weaning Practices. 47 9.1 Initiation of Breastfeeding . 47 9.2 Mean Duration and Frequency of Breastfeeding . 48 9.3 Reasons for Never Breastfeeding and for Stopping Breastfeeding . 48 9.4 Supplementation and Weaning Practices . 48 10. Immunization Levels . 51 11. Child Morbidity and Mortality . 55 11.1 Prevalence of Diarrhea and Its Treatment . 55 Prevalence of Diarrhea. 55 Treatment of Diarrhea. 56 Diets of Children with Diarrhea . 57 11.2 Prevalence of Acute Respiratory Illness and Its Treatment . 58 Prevalence of ARI. 58 Treatment of ARI. 59 11.3 Infant and Child Mortality . 60 12. Knowledge of AIDS . 65 References . 69 Appendix A: Household Amenities Appendix B: Acronyms Appendix C: List of Figures Appendix D: List of Tables Tables Appendix E: Sampling Error 1 Summary Introduction The 1991 Belize Family Health Survey was de- signed to examine fertility, child morbidity and mortality, contraceptive behavior, use of health services, and knowledge of AIDS in Belize. The survey was conducted by the Central Statistical Office (CSO) of the Ministry of Finance, with technical assistance from the Division of Reproductive Health, Centers for Disease Control. The United States Agency for International Development (AID) provided the funding for the survey. During fieldwork, which was conducted January 15 to February 19, 1991, 2,656 women 15-44 years of age were interviewed. A preliminary report was released by the Central Statistical Office in May, 1991 (Central Statistical Office et al., 1991). The Centers for Disease Control, with the assistance of the Central Statistical Office, prepared this report. Fertility The total fertility rate (TFR) estimated from the 1991 survey is 4.5. Differentials in fertili- ty are in the expected direction, with the largest differentials being between urban and rural areas (almost 2 children per woman), levels of education (with a difference of nearly 3 children between the lowest and highest educational levels), and socioeconomic levels (almost 4 children between the lowest and highest levels). The highest TFR's are for women who live in low socioeconomic house- holds (6.7), measured by the number of ameni- ties reported to be in the household (see Ap- pendix A), and for women of low educational attainment (6.0). The lowest TFR's are for women who live in high socioeconomic house- holds (2.7) and working women (2.9). Survey data show that moderately sized fami- lies are much desired in Belize. However, on average, women with children have already exceeded their preferred family size of 3.4 children. The total fertility rate is greater than the reported ideal family size. This is due to the excess fertility of older less educated women. Knowledge and Use of Contraception Knowledge of contraception is high in Belize, as 95 percent of women 15-44 years of age had knowledge of at least one modern method. However, there was a wide variation in knowl- edge of individual methods. The best known methods were oral contraceptives, female sterilization, and injectables, while the least known methods included diaphragms, with- drawal, and the Billings method. Rural wom- en, women of low educational attainment, and women whose ethnic group is either Maya or Ketchi were the least familiar with contracep- tive methods. Forty-seven percent of married women or women living in consensual unions (referred to as "married women" in this report) were found to be using contraceptive methods at the time of the survey. The most prevalent method used by married women in Belize is female sterilization, which accounts for 40 percent of all contraceptive use. The second and third most prevalent methods are oral contraceptives and injectables. Urban areas of the country have the highest contraceptive prevalence rate with 55 percent of married women reporting current use com- pared to 33 percent of married women living in rural areas. As age and number of living children of the respondents increase, so does the prevalence of contraceptive use. By the time married women are 30 years of age or older and/or have two or more children, more than 50 percent are using some form of contra- 2 ception. The use of reversible methods de- clines with an increase in age and number of living children as an increasing percentage of women rely on sterilization. Female steriliza- tion accounts for 76 percent of total use among women aged 40-44. Use of contraceptive methods was found to be directly associated with educational attainment and socioeconomic status. Differences in contraceptive prevalence were also seen ac- cording to ethnic group and principal language spoken in the household. Creole women reported the highest prevalence (53 percent) while the Maya/Ketchi reported the lowest prevalence (25 percent). The highest preva- lence was also reported by married women living in households where English is the principal language (62 percent), while the lowest prevalence was reported by married women who live in households where Maya is the principal language (10 percent). Two thirds of the married women who were using contraception at the time of the survey reported that they were using to limit their family size. By the time women are 25-29 years of age or have three living children, over half want to limit their childbearing. Interest- ingly, half of the users of rhythm, the Billings method, vaginal methods, and condoms were using these methods to limit family size. The median age and mean number of living children at the time of a woman's first contra- ceptive use was 27.9 years of age and 3.8 living children. Source of Contraception The most important suppliers of contraceptives (excluding withdrawal and natural methods) in Belize in 1991 were the Ministry of Health (41 percent), pharmacies (31 percent), private clinics and hospitals (13 percent), and the Belize Family Life Association (BFLA), the International Planned Parenthood Federation affiliate in Belize (11 percent). The Ministry of Health was the principal source of steriliza- tion in the country, while pharmacies were the major suppliers of oral contraceptives and condoms. The BFLA was the principal source for users of injectables, and private clinics/- hospitals were the principal suppliers of IUD's. Reasons for Nonuse of Contraception and Desire to Use in the Future The most important reasons for not using contraception were reasons related to pregnan- cy, fecundity, and lack of sexual activity, which were given by 59 percent of married nonusers. The major reasons for nonuse not related to pregnancy and sexual activity were fear of side effects from the use of contracep- tion (9 percent), dislike of contraception (8 percent), and lack of knowledge of contracep- tive methods (8 percent). Less than one per- cent of nonusers stated they were not using because of religious reasons. Fifty-four percent of fecund nonusers want to use a method of contraception in the future. The proportion wanting to use in the future was highest among nonusers living in urban areas, among nonusers less than 30 years of age, and among nonusers with fewer than four living children. Of the women who desire to use in the future, three fourths knew where to obtain contraception. The most frequently desired methods were oral contraceptives, female sterilization, and injectables. The most frequently mentioned sources of contraception included pharmacies, government facilities, and the BFLA. Risk of an Unplanned Pregnancy The survey data indicate that certain segments of the population are at greater risk of an unplanned pregnancy than others. Women defined as at risk of an unplanned pregnancy are fecund, sexually active women, who were not pregnant at the time of the survey, did not desire to become pregnant, and were not using a method of contraception. Overall, 17 per- 3 cent of all women aged 15-44 are at risk of an unplanned pregnancy, or "in need of family planning services." Fifty-four percent of the women at risk live in urban areas. Slightly more than 88 percent are married or live in a consensual union, 78 percent have a primary school education or less, two thirds have three or more children, and 57 percent are under the age of 30. Thus, the survey data indicate that the family planning program of Belize should be oriented toward young, high parity, mar- ried, and less educated women who live in both urban and rural areas. Surgical Contraception Female sterilization is the most prevalent method of contraception in Belize, accounting for 40 percent of all contraceptive use. The average age at sterilization is 29.7 years, and 71 percent of sterilized women have four or more living children. Tubal ligation is the first method of contraception for 38 percent of sterilized women and for 58 percent of steril- ized women living in rural areas. Ninety-three percent of sterilized women expressed satisfac- tion with their decision to have the operation, with satisfaction being somewhat lower (85 percent) for women who were 15-24 years old when they were sterilized. Among fecund married women who did not want any more children, 38 percent said they were interested in sterilization. Use of Maternal and Child Health Services Married women who had one or more live births during the five years prior to the survey interview were asked which maternal and child health services they had received. Ninety-five percent of the women reported that they re- ceived prenatal care while pregnant, but only 40 percent reported receiving a postpartum checkup. Interestingly, only 58 percent of the women took their newborns for a checkup. Only 34 percent of the women used all three services. Conversely, only 2 percent of the women did not use any of the MCH services. More than three fourths of deliveries took place in either a government or private hospi- tal. Eight percent of the hospital deliveries were Cesarean. Overall, 21 percent of the children were delivered at home, with 40 percent of rural women and 46 percent of the Maya and Ketchi reporting home deliveries. Sixty percent of all deliveries were attended by a nurse midwife while an additional 17 percent were attended by physicians. One fifth of the deliveries were attended by a traditional birth attendant. Breastfeeding and Weaning Practices Overall, 90 percent of children under 24 months of age were reported to have ever been breastfed. the mean duration of breastfeeding is 12 months. The main reasons for never breastfeeding is the infant's refusal to suckle (44 percent) and the mother's inability to nurse (18 percent). Only 24 percent of infants were breastfed exclusively for the first three months, and 41 percent of infants were predominantly breastfed for the first three months of life (i.e. they were given only the liquids water, sugar water, juice, and tea in addition to breastmilk). Immunization Levels Levels of completed primary immunization ranged from 81 percent for DPT to 89 percent for BCG. Levels are 8 percent to 10 percent higher when only children with vaccination certificates are considered. Overall vaccination coverage in Belize for children 9 to 59 months of age is 75 percent. Only 47 percent of children are completely immunized before their first birthday. These findings indicate that, although Belize is close to achieving levels of immunization that are necessary to control the transmission of disease, children are vaccinated later than recommended. 4 Prevalence of Diarrhea and Its Treatment Nearly 11 percent of children less than five years of age had a diarrheal illness during the two weeks prior to interview. Prevalence of diarrhea was highest in rural areas and among children 6 months to 23 months of age. Chil- dren living in crowded conditions, whose sanitary services were either a pit latrine or none, and whose source of drinking water was unprotected were more likely to have had diarrhea than children living in better condi- tions. Overall, 83 percent of children with diarrhea were reported to have been treated for their recent episode of diarrhea. Oral rehydra- tion therapy (packets of oral rehydration salts and/or homemade salt and sugar solutions) was the primary method of treatment. Twenty-four percent of the children were treated with antibiotics, which is generally not an indicated treatment since they are not effective against viruses, the major cause of diarrhea. Forty- four percent of the mothers reported that they continued feeding their children a normal diet during their recent diarrheal illness and 29 percent substituted soft foods. Overall, only 56 percent of the mothers increased liquids. Prevalence of Acute Respiratory Illness and Its Treatment Forty percent of children under 5 years of age were reported to have presented symptoms associated with ARI in the two weeks prior to interview. The percentages of children with signs of Acute Respiratory Illness (ARI) were highest among those living in urban areas, children of mothers with lower educational attainment, and among children less than two years of age. Mild episodes of respiratory illness were the most prevalent form of ARI reported. Either at home or in a health facili- ty, eighty-six percent of the children that presented ARI symptoms were treated. The most common treatment given to children included expectorants, unspecified pills and/or syrups, and aspirin. Thirty percent of the chil- dren were treated with antibiotics, an inappro- priate therapy for most cases of ARI since over 90 percent of ARIs are viral in origin. Infant and Child Mortality Infant mortality for the period immediately before the survey is estimated to be 42 deaths for every 1000 live births. Mortality occurring to children before reaching their fifth birthday is estimated at 53 deaths per 1000 live births. Knowledge of AIDS Knowledge of AIDS is almost universal in Belize, as 97 percent of all women aged 15-44 reported that they have heard of AIDS. How- ever, fewer rural women (92 percent) than urban women (99 percent) had heard of AIDS. While more than 90 percent of the women knew of the correct modes of transmitting AIDS, over 50 percent believed that AIDS can be transmitted by giving blood or by being bitten by an insect. Of the women who have heard of AIDS, one third believe that they are at some risk of getting AIDS. A higher per- centage of urban women (37 percent) than rural women (25 percent) believe that they are at risk. Fifty-three percent of women in visiting partner relationships felt that they were at some risk of getting AIDS. Of the women who perceive themselves to be at either great or some risk of getting AIDS, only 2 percent were found to be currently using condoms. 5 1. Introduction Belize is one of the countries in Latin America that was not included in the World Fertility Survey, the Contraceptive Prevalence Survey project, or the Demographic and Health Sur- vey program during the 1970's and 1980's. As a result, data on contraceptive prevalence and the use of maternal and child health servic- es in Belize has been limited. The 1991 Fami- ly Health Survey was designed to provide health professionals and international donors with data to assess infant and child mortality, fertility, and the use of family planning and health services in Belize. The objectives of the 1991 Family Health Survey were to: • obtain national fertility estimates; • estimate levels of infant and child mortality; • estimate the percentage of mothers who breastfed their last child and duration of breastfeeding; • determine levels of knowledge and current use of contraceptives for a variety of social and demographic background variables and to determine the source where users obtain the methods they use; • determine reasons for nonuse of contracep- tion and estimate the percentage of women who are at risk of an unplanned pregnancy and, thus, in need of family planning services; and • examine the use of maternal and child health services and immunization levels for children less than 5 years of age and to examine the prevalence and treatment of diarrhea and acute respiratory infections among these children. Ethnicity in Belize Although small in size, Belize is rather unique within Central America because of its ethnic diversity. Formerly British Honduras, Belize obtained its independence from Great Britain in 1981. It has a current population just under 200,000 people and is comprised of four major ethnic groups: Creoles, Mestizos, Garifuna, and Maya/Ketchi. The Creoles are of mixed African and European ancestry. The Mestizos, primarily a mixture of Spanish settlers and Native Americans (Grant, 1976:16), have immigrated to Belize over the past two centu- ries. A large number of Mestizos have also immigrated to Belize during the past twenty years as a result of civil conflicts in neighbor- ing Central American countries (McCommon, 1989:93-94; Everitt, 1984). The earlier Mesti- zo immigrants have become well integrated into the economy and occupy a class position similar to that of the Creoles. The Mestizos who came to Belize within the past 20 years are primarily agricultural workers or unskilled laborers. The Garifuna, or Black Carib, are a mixture of African and Carib Indians. They started out in St. Vincent but were transported forcibly by the British in 1796 to Roatan, an island off the coast of Belize (Kerns, 1985:19). From there, the Garifuna settled in both Honduras and Belize. Today the Garifuna of Belize live in towns and are primarily involved in fishing and teaching. The various native American groups which we will refer to interchangeably as Mayas or Maya/Ketchi have been on Belizean soil the longest—as early as 1500 B.C. The Maya were devastated by conflicts and diseases brought to the New World by Spanish explor- ers in the 16th century and more recently by British logcutters several hundred years later 6 (Bolland, 1977 :17-24). Today, the term "Maya" actually refers to several groups of Indians. One is the Mopan Maya, some of whom migrated from Guatemala, and the Ketchi Indians who also migrated from Guate- mala. Currently, the Maya/Ketchis live mostly in the rural areas of Belize and are involved in farming. The Maya/Ketchis marry primarily within their own communities (Dobson, 1973:252-255), as do the Mestizos. The official language of Belize is English, which is taught in all public schools. Howev- er, each ethnic group speaks its own native language. The Creoles speak Creole, the Garifuna speak Garifuna, the Mestizos speak Spanish, and the Maya/Ketchi speak Maya/- Ketchi. The Maya/Ketchis and the Mestizos are less likely than the Creoles and Garifuna to speak English and Creole, the two principal languages of commerce in the country. 7 2. Methodology The 1991 Belize Family Health Survey was an area probability survey with two stages of selection. The sampling frame for the survey was the quick count of all households in the country conducted in 1990 by the Central Statistical Office in preparation for the 1991 census. Two strata, or domains, were sampled independently: urban areas and rural areas. In the first stage of selection for the urban domain, a systematic sample with a random start was used to select enumeration districts in the domain with probability of selection pro- portional to the number of households in each district. In the second stage of selection, households were chosen systematically using a constant sampling interval (4.2350) across all of the selected enumeration districts. The enumeration districts selected for the rural domain were the same as those that had been selected earlier for the 1990 Belize Household Expenditure Survey. The second stage selec- tion of rural households was conducted the same way it was for the urban domain but used a constant sampling interval of 2.1363. In order to have a self-weighting geographic sample, 3,106 urban households and 1,871 rural households were selected for a total of 4,977 households. Because the Central Statistical Office was involved in other projects, namely an on-going Household Expenditure Survey and prepara- tions for the national census scheduled to begin in May 1991, the time allocated for imple- menting and completing this survey was ex- tremely limited. Thus, pretesting of the ques- tionnaire and training of supervisors and inter- viewers were completed in just 10 days. Normally, for a survey of this magnitude and complexity, two weeks are set aside for train- ing and three months for field work. Original- ly, only three weeks were allocated for field- work, but after the second week of fieldwork it was extended to five weeks. The accelerated schedule for fieldwork essentially eliminated the possibility of providing feedback to field supervisors and interviewers on inconsistencies and omissions found in questionnaires at the data entry point. Consequently, extensive editing of the survey data set was required following fieldwork. Only one woman aged 15-44 per household was selected for interview. Each respondent's probability of selection was inversely propor- tional to the number of eligible women in the household. Thus, weighting factors were applied to compensate for this unequal proba- bility of selection. In the tables presented in this report, proportions and means are based on the weighted number of cases, but the unweighted numbers are shown. Fieldwork was conducted from January 15 to February 19, 1991. Of the 4,977 households selected, 4,566 households were visited (Table 2-1). Overall, 8 percent of households could not be located, and 7 percent of the households were found to be vacant. Less than 3 percent of the households refused to be interviewed. Fifty-five percent of sample households include- ed at least one woman aged 15-44. The bot- tom panel of Table 2-1 shows that complete interviews were obtained in 94 percent of the households that had an eligible respondent, for a total of 2,656 interviews. Interview comple- tion rates did not vary by residence. Characteristics of Currently Married Respondents Table 2-2 summarizes the characteristics of the 1,672 currently married respondents aged 15- 44, by ethnic group. In this and subsequent tables, language refers to the language usually spoken in the household. The linguistic diver- sity of the ethnic groups is important and varies on a homogeneity-diversity continuum 8 with the Creoles and Mestizos being the most homogenous and the Garifuna and the Ma- ya/Ketchi being the most diverse. For exam- ple, Creoles primarily speak Creole in their households and Mestizos speak Spanish. In contrast, almost an equal percentage of Gari- funas and Maya/Ketchis speak the language native to their ethnic group or another lan- guage. While Creole is the second most spoken language of the Garifunas, Spanish is the second most spoken language of the Ma- ya/Ketchi. Since most health services in Belize are provided by English or Creole speakers, Mestizos and the Maya/Ketchi may have the greatest difficulty in obtaining health care. If language is a factor, then the Garifuna and the Creoles may be similar in terms of their use of health services as should the Mestizos and the Maya/Ketchi. Area of residence can also be a factor in obtaining health services. The tropical terrain and lack of roads, especially all-weather roads, in rural areas may act as obstacles to rural women in obtaining health care. The majority of the Maya/Ketchi (79 percent) live in the rural areas of Belize. Almost half (45 percent) of the Mestizos live in rural areas. Eighty- three percent of the Creoles and nearly three fourths of the Garifuna live in urban areas. If residence is a barrier to obtaining health care in Belize, then this would affect the Maya/- Ketchi the most and the Mestizo population to a somewhat lesser extent. The Creole are the most educated of all the ethnic groups, with 88 percent having had more than eight years of formal education. They are followed by the Garifuna, of which 85 percent have achieved eight or more years of education. In contrast, only 48 percent of the Mestizos and 38 percent of the Maya/- Ketchi reported having eight or more years of education. Since education is positively corre- lated with the utilization of maternal and child health services, the Mestizos and the Maya/- Ketchis again may be at the greatest disadvan- tage in terms of health care utilization. Fig- ure 2-1 gives the distribution of women by educational level and age. It can be seen that younger women tend to have higher levels of educational attainment. Thirty-one percent of the Mestizos and nearly 10 percent of the Maya/Ketchi reported that they were born outside of Belize. The survey did not determine their legal status in Belize or how recently they had immigrated. Guatemala and El Salvador were the principal countries of birth among the Mestizos who were born outside of Belize, while Guatemala and Mexico were the principal countries of birth among the Maya/Ketchi. Two to three times as many of the Creole and Garifuna women who were interviewed report- ed that they have jobs for which they are paid in cash or in kind compared to Mestizos and the Maya/Ketchi. The majority of Mestizos and Garifuna and 54 percent of the Maya/Ketchi reported that they were Catholic. In contrast, more than six out of ten Creoles stated that they were Protestant. 9 10 Table 2-1 Belize: Interview Status, by Residence 1991 Family Health Survey (Percent Distribution) Residence Interview Status Total Urban Rural Household Selection Eligible respondent identified No eligible respondent Household not located/visited Vacant household Refusal Resident not home Other Total No. of Households 55.4 23.5 8.0 7.3 2.6 1.5 1.5 100.0 (4,977) 57.4 23.2 7.8 4.9 3.3 1.4 1.9 100.0 (3,106) 52.0 24.0 8.4 11.4 1.4 1.7 1.0 100.0 (1,871) Individual Selection Completed interview Individual refusal Respondent not home Other Total No. of Possible Respondents 94.0 2.8 0.8 2.3 100.0 (2,824) 93.6 2.7 0.6 3.1 100.0 (1,841) 94.8 2.9 1.3 0.9 100.0 (983) No. of Complete Interviews (2,656) (1,724) (932) NOTE: Totals in this and subsequent tables may not equal 100 percent due to rounding. Table 2-2 Belize: Percent Distribution of Characteristics of Currently Married Women Aged 15-44, by Ethnic Group Ethnic Group Selected Characteristics Creole Mestizo Garifuna Maya/ Ketchi Household Language English Creole Spanish Garifuna Mayan Rural Residence Yes No Age 15-24 25-34 35-44 Immigrant Yes No Currently Working Yes No Roman Catholic Yes No Total 8.1 88.1 3.8 0.0 0.0 16.9 83.1 25.7 47.4 26.9 1.7 98.3 36.9 63.1 38.2 61.8 100.0 2.9 11.3 85.8 0.0 0.0 45.5 54.5 28.1 43.5 28.3 31.1 68.9 15.4 84.6 65.0 35.0 100.0 4.2 46.4 3.6 45.8 0.0 26.2 73.8 26.2 47.6 26.2 7.7 92.3 35.3 64.7 85.1 14.9 100.0 3.5 7.5 41.0 2.0 46.0 79.5 20.5 37.0 37.0 29.0 9.5 90.5 11.0 89.0 54.0 46.0 100.0 No. of Cases (Unweighted) (N=474) (N=890) (N=137) (N-171) 11 3. Fertility This chapter is concerned with describing levels, trends, and differentials in fertility in Belize. The first section presents estimates of fertility for the five years before the 1991 survey. Age-specific fertility rates are present- ed for different population subgroups. The second section presents estimates of marital fertility in the five years before the survey, based on the reporting of ever-married women. The third section deals with retrospective fertility, describing the cumulative childbearing experience of women during their lifetimes. The fourth section deals with the timing of marriage and duration of breastfeeding, which are the two major non-contraceptive determi- nants of fertility. The other major determinant of fertility, use of contraception, is dealt with at length in Chapter 5. The fifth section of this chapter deals with the planning status of the last pregnancy, current pregnancy intentions, and desire for more children. 3.1 Levels and Differentials For each woman interviewed in the 1991 survey, dates of up to 14 live births were recorded. This information can be used to calculate age-specific fertility rates for periods of time prior to the survey. Table 3-1 shows the number of births, classified by age of the mother at each birth, woman-years of expo- sure, and age-specific fertility rates (ASFRs) for the period February, 1986 - January, 1991. The estimated Total Fertility Rate (TFR) is 4.5, which can be interpreted as the average number of children that would be born to a woman over her lifetime if she experienced the age-specific rates for this five year period. Table 3-2 shows differentials in the ASFRs and TFR by residence (urban/rural), level of edu- cation, number of household (HH) amenities (see Appendix A), ethnicity, religion, and economic activity of the mother. Differentials by residence and education are seen in Figures 3-1 and 3-2. Differentials are in the expected direction, with the largest differentials between urban and rural areas (almost 2 children per woman), by level of education (with a differ- ence of 2.8 children between lowest and high- est education levels), and by number of house- hold amenities (with a difference of 4 chil- dren). There are also sizable differentials between ethnic groups (3.6 children per wom- an for Creoles, 4.8 for Mestizos, and 5.4 for "Other" which includes the Garifuna on the coast and the Maya/Ketchi in the interior). The highest TFR's are for women reporting no education (6.0), and for women living in households with fewer than 3 amenities (6.7). The lowest TFR's are for women with second- ary or higher levels of education (3.2), women who live in households with at least 8 of 10 selected amenities (2.7), and for women who were working at the time of the survey (2.9). According to Table 3-2, the modal age group of childbearing is at ages 20 to 24. This is true for virtually all subgroups of women, and is consistent with early marriage patterns, usually before ages 22 or 23, and the initiation of contraception by married women only after having several children in the first three to five years of marriage. The only exceptions to this general pattern are women working outside the home, for whom the modal age group of childbearing is at ages 25 to 29. This indicates greater delays than typical in age at marriage for these women. 3.2 Marital Fertility Since most childbearing in Belize takes place within marriage or consensual unions, it is useful to consider fertility for married women only. As used here, the term marriage in- cludes women in legal and consensual unions. Since the survey provides information on the 12 date of first union for women who have ever been in a union, it is straightforward to calcu- late marital fertility rates by duration since first union. Table 3-3 shows the number of births and woman-years of exposure classified by duration since first union, and duration-specific marital fertility rates for the period from February 1986 to January 1991. It also shows a total marital fertility rate (TMFR) of 5.5, which represents the average number of chil- dren that would be born to a group of women who were married and who over their lifetimes experienced the duration-specific fertility rates shown in Table 3-3. Some caveats should be noted regarding the denominators used to calculate these duration- specific rates. The denominators are not adjusted to take into account the effects of divorce, widowhood, or separation. The rates are therefore based on the assumption that all ever-married women stay married throughout their reproductive ages, which makes the rates lower than if divorce, widowhood, and sepa- ration were taken into account. Since only wom- en under age 45 were interviewed, the only women contributing exposure at the later marriage durations were those who married very young. The rates at the later durations are therefore higher than would be the case if older post-menopausal women had also been included in the denominators for the duration- specific rates. The inclusion of divorced, widowed, and separated women and the exclu- sion of post-menopausal women in the denomi- nators are to some extent off-setting factors in the calculation of these marital fertility rates. Table 3-4 shows differentials in marital fertility for the same regional and socioeconomic variables as is shown for all women in Table 3-2. The differentials are very similar to those already noted for overall fertility, with the greatest differentials being between urban and rural areas, low and high socioeconomic lev- els, and between working and non-working women. The similarity of the direction and size of the differentials for total fertility and total marital fertility among all these different groups of women indicates that fertility differ- entials are due primarily to differentials in the control of fertility within marriage. The fertility-reducing effect of young women delaying marriage until after menarche is fairly uniform for the various population subgroups. It is noteworthy that fertility within marriage starts very high, with 35.3 percent of all childbearing taking place within the first five years after union; thereafter childbearing consistently drops off as duration since the first union increases. Table 3-4 also shows that those groups of women with a lower TMFR initiate childbearing at somewhat lower levels of fertility and that their fertility declines more rapidly with the passage of time than is the case for the higher TMFR groups. For example, urban marital fertility is 81 percent of rural marital fertility during the first ten years after the first union but later drops to 47 percent and is 28 percent of the rural levels at successive durations of 10-14 and 15-19 years, respectively. This indicates greater control of fertility after childbearing has begun by the lower TMFR groups. 3.3 Retrospective Fertility The previous sections have described recent fertility in the five years before the 1991 survey. This section reports on total cumula- tive fertility to women over their lifetime. Table 3-5 shows the average number of chil- dren born per woman, by age at the time of the survey, for various background characteris- tics of the women. In general, it illustrates that the differentials seen for recent fertility for the 1986-1991 period (see Table 3-2) coincide with differentials in retrospective fertility for actual cohorts of women. Women 40 to 44, who have essentially completed their childbear- ing, all experienced considerably higher fertili- ty than is reflected in the period total fertility rates estimated for 1986-1991. This indicates that fertility has been declining for women in all educational and socioeconomic subgroups, 13 as well as for women in different regions of the country. Figure 3-3 shows cumulative fertility by age for the different ethnic groups Table 3-6 provides a more detailed look at retrospective fertility for women interviewed in the 1991 survey by showing the percent distri- bution of number of children ever born, cate- gorized by age at time of the survey. The upper panel gives figures for all women, while the lower panel gives figures for women cur- rently in a union. Overall, 33.5 percent of women had not begun childbearing at the time of the survey, whereas only 7.7 percent of women currently in a union had not. Among women 40 to 44, 56 percent of all women and 58 percent of those in a union have had six or more children. 3.4 Nuptiality Age at marriage and duration of breastfeeding are two demographic variables that can poten- tially play a significant role in reducing overall fertility levels independent of the effects of conscious fertility control. Each of these vari- ables acts by reducing the proportion of the time from menarche to menopause, approxi- mately ages 15 to 49, that a woman may become pregnant. If female sexual activity is confined primarily to marriage, marrying later shortens a woman's effective reproductive age span so that she is likely to have fewer births. It also slows the rate of population growth by increasing the mean age of childbearing, which increases the doubling time of a population. Breastfeeding for longer periods of time leng- thens the time after each birth before ovulation and menstruation resume. The extent of in- crease in the postpartum anovulatory period due to breastfeeding depends on the frequency and intensity of breastfeeding and the child's age when supplementary foods are introduced. Table 3-7 and Figure 3-4 give the percent distribution of women by marital status, for selected socioeconomic and demographic vari- ables. Although few women (22 percent) enter unions during the teenage years, two thirds (68 percent) of women 20 to 24 years old have entered a union. The overall proportion single (i.e., never married) is less for women living in rural areas, for those with lower educational levels, for the Mestizos and Maya/Ketchi and for those reporting no religion. Since marriage is nearly universal in Belize, this is primarily a function of variations in the age at marriage for these subgroups of the population. Con- sensual unions, as opposed to formal marriag- es, are most common for the Garifuna (31 percent) and visiting relationships for the Creoles (10 percent). Widowhood is rare, except for women 40 and over. Only 2.4 percent of women are divorced or separated, with somewhat higher proportions among women in urban areas (3.1 percent) and those who work (4.2 percent). Table 3-8 shows the percent of women whose first union was before selected ages, according to current age at time of the survey. For those aged 25 and above, there has been little change in the age of entry into marriage, except the proportion marrying before age 18 has de- clined slightly from 34.5 to 30.7 percent. The median age at marriage is almost constant for these cohorts of women, varying between 19.9 and 21.0 years. Table 3-9 shows the median age at first union and the singulate mean age at marriage (SMAM). The median is calculated as a life table median for all women ages 15-44, in which never married women contribute expo- sure at ages up to the age at which they were interviewed. Notably, there were 134 ever- married women (5 percent) for whom the date of first union was not reported, and these women are excluded from the calculations. The SMAM is a period estimate of the average number of years of single life lived by those who eventually marry and has been included here because it is not affected by the non- reporting of date of first union. From this table it is clear that there is greater marital delay by urban women, more educated women, 14 upper socioeconomic status women, the Cre- oles and Garifuna, and women who work. 3.5 Breastfeeding Table 3-10 shows estimates of the mean dura- tion of breastfeeding. These means have been calculated from current status data on the proportion of live births in the past five years still being breastfed, classified by current age in months. Retrospective information on the age at which a child is weaned is typically inaccurate and can result in biased estimates of the duration of breastfeeding (Trussel et al, 1992). Current status data are therefore used for these estimates. The overall mean is 11.7 months. There is considerably lengthier breastfeeding by women in rural areas (4.7 months more than urban areas), but the differ- entials by other characteristics are not as pro- nounced, but larger differentials are associated with less education, lower socioeconomic status, and ethnic group. In all cases, fertility is actually lower among those groups of wom- en who breastfeed for shorter durations, indi- cating that conscious use of family planning has more than compensated for the potential contraceptive effect of more prolonged breast- feeding. 3.6 Fertility Preferences Insight into the fertility desires of a population is important for predicting future fertility. In this section, planning status of last pregnancy, current pregnancy intentions, and desire for more children are examined. Planning Status of Last Pregnancy All married women aged 15-44 who had been pregnant at least once during the last five years (including those that were currently pregnant) were asked two questions about the planning status of their last pregnancy: "When you became pregnant the last time, did you want to become pregnant?" If not, "Was it that you wanted no more children, or that you just wanted to wait longer before another pregnan- cy?" Based on the answers to these questions, each woman's last pregnancy was classified as either "planned," "mistimed," "unwanted," or "unknown." Planned pregnancies were defined as those that were desired; mistimed as those that were desired but at some time in the future; and unwanted as those that were not desired, even at a future time. Using this scheme, the mistimed and unwanted pregnan- cies can be combined as an estimate of unplan- ned pregnancies. It should be noted that women may rationalize the number of children they have, and consequently, be reluctant to state that a given pregnancy was unwanted. Thus, the data shown on unwanted pregnancies probably represents a minimum value. Based on these classifications, less than two thirds (64 percent) of the respondents' most recent pregnancies were reported as planned, 19 percent as mistimed, and 13 percent as unwanted (Table 3-11). Three percent of the pregnancies could not be classified. Thus, 32 percent of recent pregnancies were unplanned. The proportion of pregnancies that were re- ported to have been planned did not vary appreciably by place of residence. For women who reported that their last pregnancy was unplanned, a higher proportion of women in each domain said their pregnancies were mis- timed rather than unwanted. In general, the proportion of recent pregnan- cies that were planned was inversely associated with age and number of living children. With one exception, over 60 percent of women in each ethnic group reported that their last pregnancy was planned; the exception was the Garifuna, who reported that only 48 percent of their recent pregnancies were planned. Unwanted pregnancies increased with both age and number of living children. On the other hand, the percentage of pregnancies that were reported as mistimed decreased with age, indicating spacing failures at earlier ages. 15 There were no clear patterns of mistimed and unwanted pregnancies according to educational level or ethnicity of the respondents. Better educated women reported a lower level of unwanted pregnancies, probably due in part to their lower parity on the average. Current Pregnancy Intentions Table 3-12 shows current pregnancy intentions of married women aged 15-44. Overall, 71 percent stated that they did not desire a preg- nancy at the time of the survey, while 14 percent desired to become pregnant at that time. Nearly 12 percent of the women were currently pregnant. A higher proportion of women living in rural areas reported that they were currently pregnant than women living in urban areas. However, a higher proportion of urban women than rural women stated that they currently desired to become pregnant, reflecting, in part, their lower parity. As expected, the proportion of women currently pregnant or desiring a pregnancy decreases with age and number of living children. It is evident that married women with no children have strong pressures to have a child; nearly 80 percent are pregnant or desire a pregnancy. With respect to ethnicity, the Garifuna and Creoles were the most likely to report that they did not desire a pregnancy. It is noteworthy that only 4 percent of the Garifuna reported that they were currently pregnant. Nearly 12 percent of the Maya/Ketchi women were undecided about their pregnancy intentions, indicating that the decision to become pregnant may not entirely be theirs to make. Desire for More Children Another factor related to future fertility is the proportion of women who want no more children. All fecund married women who had at least one living child were asked if they wanted more children (Table 3-13). Overall, 49 percent of the women said that they did not want any more children: 46 percent in rural areas compared to 51 percent in urban areas. It should be noted that urban women want to terminate childbearing earlier in life and at lower parities than rural women. As one would expect, the proportion of women who did not want more children increased with age and family size (Figure 3-5). The bottom panel of Table 3-13 shows that Creoles were the least likely of the different ethnic groups to want more children. 16 17 18 Table 3-1 Belize: Number of Births, Woman-Years of Exposure, and Age-Specific Fertility Rates, 1986-19901 1991 Family Health Survey Age Group Births Exposure2 Age-Specific Fertility Rate3 15-19 20-24 25-29 30-34 35-39 40-44 601 863 667 340 201 39 4382 3594 3153 2285 1806 769 137 240 212 149 111 51 Total Fertility Rate 4.50 4 1February 1986 - January 1991. 231 women were excluded from the fertility analysis because they had undated births which could have occurred before or after February 1986. 3Age-Specific Fertility Rates are the annual number of births per each 1000 women in that age group during a year. 4The Total Fertility Rate is the average number of births a group of women would have during their reproductive ages, 15-44, if they were to experience the age-specific fertility rates that were in effect in a given period. Table 3-2 Belize: Age-Specific Fertility Rates and Total Fertility Rate, by Selected Characteristics 1991 Family Health Survey Age-Specific Fertility Rates Selected Characteristics 15-19 20-24 25-29 30-34 35-39 40-44 TFR No. Women Total Residence Urban Rural Education-years 0-7 8 9+ No. Household Amenities 0-2 3-7 8-10 Ethnicity Creole Mestizo Other1 Religion Protestant Catholic Work Status Not Working Working 137 117 174 237 162 74 226 125 68 109 137 191 158 120 160 81 240 224 276 299 254 181 319 36 168 204 259 261 231 245 276 167 212 193 249 244 214 174 297 197 149 177 223 242 202 213 233 168 149 122 205 168 150 122 236 142 76 115 151 191 120 160 179 91 111 82 170 172 88 48 172 108 66 85 115 140 106 122 140 50 51 35 93 83 24 47 80 60 21 25 70 49 26 68 59 31 4.5 3.9 5.8 6.0 4.5 3.2 6.7 4.3 2.7 3.6 4.8 5.4 4.2 4.6 5.2 2.9 (2625) (1710) (915) (811) (907) (907) (707) (1296) (623) (888) (1150) (588) (1021) (1450) (1862) (763) 1Includes Garifuna, Maya/Ketchi Indians, Asians, and those of European Ancestry. Table 3-3 Belize: Duration-Specific Marital Fertility Rates for the Period 1986-1991 1991 Family Health Survey Duration1 Since 1st Union Number of Births Women-Years of Exposure Duration-Specific Marital Fertility Rates 0-4 5-9 10-14 15-24 20-24 25-29 1066 598 388 179 75 6 2754 2381 2044 1491 801 115 387 251 190 120 94 52 Total Marital Fertility Rate N=1788 5.5 Women are excluded if their date of first union could not be determined or if they reported a birth without giving the birth date and it could not be determined that the birth was prior to January 1986. 1Duration is in years since first union, whether it was a marriage or consensual union. Table 3-4 Belize: Duration-Specific Marital Fertility Rates and Total Marital Fertility Rate for 1986-1991, by Selected Characteristics 1991 Family Health Survey Years Since First Union Selected Characteristics 0-4 5-9 10-14 15-19 20-24 25-29 Total Marital Fertility Rate No. Women Total1 Residence Urban Rural Mother's Education (in years) 0-7 8 9+ No. of HH Amenities 0-2 3-7 8-10 Ethnicity2 Creole Mestizo Other Religion Protestant Catholic Work Status3 Not Working Working 387 360 442 408 400 352 490 377 286 346 394 429 403 376 418 301 251 232 288 291 250 201 333 251 152 211 253 300 228 262 272 205 190 134 284 257 181 101 314 161 84 134 213 209 172 195 223 98 120 60 218 172 98 56 230 95 44 58 125 185 105 130 152 40 94 86 109 157 42 74 103 106 62 86 101 85 78 106 112 45 52 0 99 74 34 0 57 76 0 145 36 45 47 61 59 0 5.5 4.4 7.2 6.8 5.0 3.9 7.6 5.3 3.1 4.9 5.6 6.3 5.2 5.7 6.2 3.4 (1788) (1127) (661) (630) (663) (495) (530) (874) (384) (517) (849) (421) (665) (1003) (1309) (477) 1Women are excluded if their date of first union could not be determined or if they reported a birth without giving the birth date and it could not be determined that the birth was prior to January 1986. 2Excludes 1 woman for whom ethnicity was not reported. 3Excludes 2 women for whom work status was not reported. Table 3-5 Belize: Average Number of Children per Women, by Age and Selected Characteristics 1991 Family Health Survey Age at Survey Selected Characteristics 15-19 20-24 25-29 30-34 35-39 40-44 Total Residence Urban Rural Respondent's Education None Inc. Primary Complete Primary Secondary Post-Secondary No. Household Amenities 0-2 3-7 8-10 Ethnicity1 Creole Mestizo Garifuna Maya/Ketchi Other Religion None Protestant Catholic Other Work Status2 Not Working Working Total 0.2 0.4 0.9 0.6 0.3 0.1 0.0 0.4 0.3 0.1 0.2 0.3 0.3 0.4 0.5 0.7 0.3 0.2 0.2 0.3 0.2 0.3 1.3 1.7 2.8 2.0 1.5 1.1 0.4 2.2 1.3 0.9 1.2 1.5 1.7 1.9 1.7 1.7 1.5 1.4 0.8 1.8 0.8 1.5 2.4 3.5 3.8 3.6 2.8 2.0 1.4 4.0 2.7 1.7 2.3 3.0 2.8 4.0 2.6 3.9 2.7 2.7 3.3 3.1 2.1 2.8 3.5 5.1 5.3 4.8 4.1 3.3 2.3 5.8 3.8 2.7 3.6 4.1 4.4 5.5 3.2 5.5 3.8 4.0 4.5 4.6 3.0 4.0 4.5 6.6 5.9 6.1 5.2 4.2 3.0 6.7 4.9 4.2 4.7 5.3 4.9 7.1 3.6 4.5 5.1 5.3 2.0 5.8 3.9 5.2 5.5 7.6 7.7 7.1 6.1 4.8 2.9 8.0 6.4 4.5 5.4 6.3 6.8 8.8 5.6 4.9 6.0 6.3 6.0 6.8 4.6 6.1 2.3 3.1 4.7 3.6 2.9 1.4 1.3 3.5 2.5 1.9 2.1 2.8 2.6 3.6 2.9 3.1 2.5 2.6 1.9 2.8 2.0 2.6 No. of Cases (526) (549) (593) (483) (280) (225) (2656) 1Excludes 1 case for which ethnicity was not reported. 2Excludes 2 cases for which work status was not reported. Table 3-6 Belize: Percent Distribution of All Women and Women Currently in Union, by Age and Number of Children Ever Born 1991 Family Health Survey All Women Age at Survey Number of Children 15-19 20-24 25-29 30-34 35-39 40-44 Total 0 1 2 3 4 5 6 7 8 9 10+ Total 81.5 12.3 4.8 1.2 0.2 0.0 0.0 0.0 0.0 0.0 0.0 100.0 34.6 23.4 18.5 12.4 8.2 2.4 0.4 0.1 0.0 0.0 0.0 100.0 15.1 15.5 18.9 17.7 12.9 8.7 5.5 3.5 1.6 0.4 0.3 100.0 9.1 8.7 10.2 17.6 12.7 15.3 11.3 6.0 4.7 2.2 2.4 100.0 3.5 3.3 10.8 13.0 13.0 14.4 9.5 10.0 8.9 7.1 6.5 100.0 2.9 3.8 7.3 7.3 13.6 9.3 16.2 10.1 6.1 6.4 17.1 100.0 33.5 13.0 11.9 10.8 8.6 6.7 5.2 3.5 2.4 1.7 2.6 100.0 No. of Cases (526) (549) (593) (483) (280) (225) (2656) Average No. of Children 0.3 1.4 2.8 4.0 5.2 6.1 2.6 Women Currently in Union Age at Survey Number of Children 15-19 20-24 25-29 30-34 35-39 40-44 Total 0 1 2 3 4 5 6 7 8 9 10+ Total 27.3 39.5 26.7 5.2 1.2 0.0 0.0 0.0 0.0 0.0 0.0 100.0 14.0 24.1 25.2 19.9 12.4 3.5 0.7 0.2 0.0 0.0 0.0 100.0 7.3 13.5 18.4 19.7 16.1 10.7 7.1 4.7 1.7 0.4 0.4 100.0 3.2 6.5 11.3 18.7 14.3 17.3 11.6 6.0 5.5 2.8 2.8 100.0 1.0 2.6 10.3 12.5 12.8 14.1 10.3 11.5 10.3 8.0 6.7 100.0 1.1 2.1 7.7 7.3 14.7 9.1 16.8 10.1 5.9 4.9 20.3 100.0 7.7 13.2 16.4 15.7 13.2 10.0 7.9 5.4 3.8 2.5 4.3 100.0 No. of Cases (124) (359) (486) (395) (239) (187) (1790) Average No. of Children 1.2 2.1 3.2 4.4 5.5 6.4 3.8 Table 3-7 Belize: Percent Distribution of Women 15-44 Years of Age, by Marital Status and Selected Characteristics at Time of Survey 1991 Family Health Survey Marital Status Selected Characteristics Single Married Consensual Union Visiting Relationship Widowed Separated Divorced Total No. of Cases Total1 Residence Urban Rural Age 15-19 20-24 25-29 30-34 35-39 40-44 Respondent's Education None Incomplete Primary Complete Primary Secondary Post-Secondary 34.0 35.7 30.7 78.0 32.2 18.9 12.5 8.1 5.3 10.1 19.4 29.9 51.3 46.0 35.2 30.2 45.2 7.2 28.0 41.4 52.3 62.1 62.6 48.2 44.2 38.0 21.2 40.6 22.9 23.5 21.7 10.3 28.0 33.6 26.3 22.5 20.2 41.7 29.9 24.2 17.0 6.9 5.0 6.9 1.1 4.2 10.1 3.4 4.5 3.5 1.8 0.0 2.3 4.6 8.7 4.0 0.6 0.7 0.5 0.0 0.0 0.7 1.1 0.3 2.9 0.0 1.2 0.6 0.3 0.4 2.0 2.6 0.7 0.3 1.7 1.8 2.7 2.4 5.9 0.0 2.8 2.2 1.5 1.1 0.4 0.5 0.2 0.0 0.0 0.3 0.5 1.1 1.5 0.0 0.2 0.6 0.2 1.1 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (2653) (1723) (930) (526) (548) (593) (483) (280) (223) (113) (713) (917) (712) (198) 1Excludes 3 cases with unreported marital status. Table 3-7 (Continued) Belize: Percent Distribution of Women 15-44 Years of Age, by Marital Status and Selected Characteristics at Time of Survey 1991 Family Health Survey Marital Status Selected Characteristics Single Married Consensual Union Visiting Relationship Widowed Separated Divorced Total No. of Cases No. Household Amenities 0-2 3-7 8-10 Ethnicity Creole Mestizo Garifuna Maya/Ketchi Other Religion None Protestant Catholic Other Work Status Not Working Working 25.4 34.9 40.6 43.0 29.1 37.5 27.2 17.8 15.2 35.7 34.3 34.8 30.6 42.0 46.8 29.0 36.2 21.9 45.3 20.7 52.3 40.5 40.2 38.3 32.5 41.3 37.2 30.7 24.7 26.4 14.1 22.2 21.7 31.3 17.4 32.4 36.6 35.8 26.9 15.2 26.4 14.4 1.1 5.7 7.5 10.0 1.2 7.4 1.7 3.2 3.7 7.0 3.8 2.2 3.8 7.8 0.5 0.7 0.5 0.7 0.4 0.3 0.0 2.7 0.6 0.5 0.7 0.0 0.5 0.8 1.5 2.9 0.6 1.7 2.1 2.8 1.4 2.2 3.1 2.1 1.7 6.5 1.3 3.5 0.0 0.5 0.4 0.7 0.2 0.0 0.0 1.1 0.6 0.6 0.2 0.0 0.2 0.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (722) (1303) (628) (893) (1160) (228) (220) (151) (128) (1028) (1466) (31) (1886) (765) 2Excludes 1 case with unreported ethnicity. 3Excludes 2 cases with unreported work status. Table 3-8 Belize: Percent of Women Aged 15-44 Whose First Union was Before Selected Ages and Median Age at First Union, According to Age at Survey 1991 Family Health Survey Age at Survey Age at First Union1 15-19 20-24 25-29 30-34 35-39 40-44 < 15 < 18 < 20 < 22 < 25 Ever in Union Median Age at First Union2 (3.8) (15.3) (17.8) * * 17.8 * 3 10.2 26.9 44.4 (53.9) (60.2) 60.2 21.0 9.7 30.7 46.7 60.6 76.0 81.6 20.6 7.9 33.1 50.5 62.8 77.3 87.7 19.9 8.9 34.5 48.8 62.9 77.6 90.2 20.2 4.5 25.9 49.5 66.5 82.1 95.5 20.1 No. of Cases (516) (530) (556) (454) (262) (204) 1Excludes 131 cases (4.9%) of ever-married women with date of first union not reported. 2Median age at first union calculated as a life table median in which never-married women contribute exposure at ages up to the age at which they were interviewed. 3( ) indicates incomplete exposure by this cohort of women at these ages. Table 3-9 Belize: Median Age at First Union and SMAM1 for All Women Aged 15-44, by Selected Characteristics 1991 Family Health Survey Selected Characteristics Median Age at2 First Union SMAM No. of Cases Total 20.7 21.2 (2656) Residence Urban Rural Respondent's Education None Incomplete Primary Complete Primary Secondary Post-Secondary No. Household Amenities 0-2 3-7 8-10 Ethnicity3 Creole Mestizo Garifuna Maya/Ketchi Religion Protestant Catholic Work Status4 Not Working Working 21.5 18.9 18.0 18.3 20.5 22.2 23.7 18.4 20.9 22.4 22.2 19.8 22.4 18.2 21.4 20.5 19.7 22.8 21.6 20.4 18.0 19.5 21.0 22.6 22.0 19.6 21.6 22.2 21.6 21.1 22.0 20.1 21.1 21.7 20.6 22.6 (1724) (932) (113) (714) (918) (713) (198) (723) (1305) (628) (894) (1164) (228) (220) (1031) (1466) (1888) (766) 1Singulate Mean Age at Marriage (SMAM) is a period estimate of the average number of years of single life lived by those who eventually marry in a cohort that at successive ages exhibited the same proportions single as observed in a cross section of women observed at the same point in time. 2Excludes 131 with missing date of first union. 3Excludes 1 case for which ethnicity was not reported. 4Excludes 2 cases for which work status was not reported. Table 3-10 Belize: Mean Duration of Breastfeeding,1 by Selected Characteristics 1991 Family Health Survey Selected Characteristics Mean Duration of Breastfeeding Number Live Births Total Residence Urban Rural Education (years) 0-7 8 9+ No. Household Amenities 0-2 3-7 8-10 Ethnic Group Creole Mestizo Other Religion Protestant Catholic Work Status Not Working Working 11.7 9.6 14.3 12.8 11.6 10.3 11.4 8.6 8.0 9.3 12.3 13.1 11.0 12.5 12.4 9.2 (2275) (1269) (1006) (952) (792) (531) (915) (1047) (313) (593) (1084) (598) (835) (1265) (1817) (458) 1Mean Duration of Breastfeeding is calculated from current status data on the proportion of live births in the past five years still being breastfed, classified by current age in months. Mean BFDUR = .5*S(0)+S(1)+S(2)+.+S(58)+S(59), where S(i) gives the proportion currently breastfed among children born i months before the month of the interview. Table 3-11 Belize: Planning Status of Last Pregnancy, by Selected Characteristics: Currently Married Women Aged 15-44 Who Had Been Pregnant During the Last Five Years 1991 Family Health Survey (Percent Distribution) Unplanned Selected Characteristics Planned Mistimed Unwanted Unknown Total No. of Cases (Unweighted) Total Residence Urban Rural Age 15-19 20-24 25-29 30-34 35-39 40-44 No. of Living Children 0 1 2 3 4 5 6+ Years of Education 0-7 8 9+ Ethnic Group* Creole Mestizo Garifuna Maya/Ketchi Other 64.5 63.4 66.1 74.5 62.6 64.3 67.8 61.6 52.9 90.8 79.7 69.7 62.6 58.2 53.9 53.1 66.3 60.9 66.5 60.6 68.9 48.1 64.5 63.4 19.1 19.3 18.8 22.1 27.6 19.3 15.2 10.3 4.9 5.3 15.6 24.6 26.0 18.1 21.6 13.6 17.0 19.9 21.4 21.2 16.1 28.7 20.7 20.7 13.0 13.9 11.7 0.7 5.5 12.8 13.1 26.0 40.2 0.0 0.0 4.5 8.7 16.9 20.4 30.7 13.9 15.6 7.7 13.4 12.3 21.3 9.5 13.4 3.4 3.4 3.4 2.7 4.2 3.5 3.8 2.0 2.0 3.9 4.6 1.1 2.6 6.8 4.2 2.6 2.7 3.5 4.4 4.8 2.6 1.9 5.3 2.4 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (1,274) (711) (563) (108) (320) (392) (270) (117) (67) (55) (182) (235) (241) (158) (160) (243) (530) (430) (314) (316) (647) (89) (146) (75) *Excludes one case for whom ethnic group is unknown. Table 3-12 Belize: Current Pregnancy Intention of Currently Married Women Aged 15-44, by Selected Characteristics 1991 Family Health Survey (Percent Distribution) Selected Characteristics Currently Pregnant Desire Pregnancy Don't Desire Pregnancy Unknown Total No. of Cases Unweighted Total Residence Urban Rural Age 15-19 20-24 25-29 30-34 35-39 40-44 No. of Living Children 0 1 2 3 4 5 6+ Years of Education 0-7 8 9+ Ethnic Group* Creole Mestizo Garifuna Maya/Ketchi Other Contraceptive Use Currently Using Not Using 11.7 9.8 14.8 20.3 18.7 14.6 8.8 6.1 1.0 32.6 15.0 10.1 10.8 7.8 8.1 7.6 13.7 9.9 11.3 10.2 13.1 4.2 14.5 12.6 0.0 21.9 14.0 15.2 12.2 15.7 17.1 18.9 11.5 12.5 4.9 46.9 24.3 13.1 14.6 4.6 7.2 4.0 13.7 12.1 17.5 13.1 14.3 16.7 10.5 17.8 9.7 17.9 71.0 73.3 67.5 57.6 61.2 62.9 76.0 79.5 92.3 14.9 57.7 74.4 72.1 85.2 80.1 84.8 68.1 75.0 69.8 75.0 69.7 78.0 63.5 67.4 88.9 55.4 3.2 1.8 5.5 6.4 3.0 3.6 3.7 1.9 1.7 5.7 3.0 2.4 2.5 2.5 4.5 3.6 4.6 3.0 1.5 1.7 3.0 1.2 11.5 2.2 1.4 4.9 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (1,790) (1,077) (713) (124) (359) (486) (395) (239) (187) (137) (234) (333) (319) (237) (198) (332) (679) (645) (466) (474) (890) (137) (171) (117) (848) (942) *Excludes one case for whom ethnic group is unknown. Table 3-13 Belize: Percent of Currently Married Fecund Women Aged 15-44 Who Want No More Children, by Selected Characteristics and Residence 1991 Family Health Survey Residence Selected Characteristics Total Urban Rural Total Age 15-19 20-24 25-29 30-34 35-39 40-44 No. of Living Children 1 2 3 4 5 6+ Years of Education 0-7 8 9+ Ethnic Group* Creole Mestizo Garifuna Maya/Ketchi Other 49.0 15.3 37.9 42.8 58.3 69.5 83.9 14.4 37.0 46.0 65.4 69.7 78.4 49.8 51.7 44.2 53.5 48.9 44.9 45.4 43.0 (1,258) (92) (294) (387) (268) (142) (75) (219) (282) (247) (156) (135) (219) (510) (418) (330) (324) (631) (88) (132) (82) 51.5 22.2 43.2 42.2 58.7 75.5 84.9 18.9 43.1 53.1 70.5 83.1 87.6 56.0 56.6 43.9 55.7 50.9 47.4 ** 41.3 (707) (40) (165) (232) (151) (79) (40) (147) (184) (153) (85) (66) (72) (198) (222) (287) (262) (304) (64) (23) (54) 45.7 10.0 30.0 43.7 57.8 62.9 82.7 5.3 24.8 32.6 58.4 56.3 73.9 45.7 45.5 46.1 43.7 46.8 ** 45.3 46.7 (551) (52) (129) (155) (117) (63) (35) (72) (98) (94) (71) (69) (147) (312) (196) (43) (62) (327) (24) (109) (28) *Excludes one case for whom ethnic group is unknown. **Less than 25 cases. 19 4. Attitudes Towards Childbearing This chapter deals with a variety of attitudes and opinions related to childbearing. These include preferences about ideal family size and the interval between births, who should make decisions about using contraception, and rea- sons for wanting to limit family size. 4.1 Ideal Family Size All women aged 15-44 who did not have any living children were asked, "If you could choose exactly the number of children to have in your whole life, how many would that be?" Similarly, all women with at least one living child were asked, "If you could go back to the time when you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?" The responses to these questions has been termed "ideal family size." In interpret- ing the responses of the women who have children, it should be remembered that women may tend to rationalize the number of children they already have and, consequently, may be reluctant to state a number that is less than their achieved family size. Less than 15 percent of the respondents gave a non-numeric response to either of the two hypothetical questions on ideal family size. Only women who gave numeric responses are included in the following discussion. The mean ideal family size is 3.4 children for women who have living children (Table 4-1) and 2.9 children for women who do not have any living children (Table 4-2). As shown in both tables, rural women and older women prefer larger families than urban and younger women. For women with children, ideal family size increases as years of schooling decreases; for women without children there is very little difference in preferred family size across the education categories. Similarly, ideal family size does not vary appreciably by religious affiliation. With respect to ethnicity, Creoles have the smallest ideal family size while the Maya/Ketchi have the largest ideal family size. Focusing only on women who have children, Table 4-1 shows that the actual fertility of some groups of women in Belize is greater than their stated ideal family size. Overall, women with children have already exceeded their preferred family size. Major contributors to this excess are women 35-44 years of age and women with less than eight years of school- ling. It should be noted that women 30 years of age or older have already exceeded their ideal family size. In summary, moderately sized families are much desired in Belize. A comparison of the mean ideal family size for women who do not have children with that of women who have children suggests that if women who currently do not have any children have only the number they desire, fertility will decline in Belize in the future. It should be noted that ideal family size reported by both groups is less than the total fertility rate. This discrepancy is due to the excess fertility of older less educated women. 4.2 Opinions About Childbearing All women aged 15-44 were asked a series of questions on childbearing. The intent of these questions was to explore reasons why a woman might want to limit her family size, what the ideal interval between children should be, who should decide the number of children a couple wants to have, and who should decide the use of contraceptive methods. Nearly two thirds of the respondents stated that both partners in a relationship should decide the number of children a couple wants to have 20 (Table 4-3). Twenty-one percent stated that it should be left up to the woman and 8 percent stated that the man should decide. Twice the proportion of urban women compared to rural women felt that the woman should decide. In addition, approximately 30 percent of Creole and Garifuna women felt that it was the re- sponsibility of the woman to decide (Table 4- 4). While only 4 percent of the women stated that the number of children to have should be "left up to God," 17 percent of the Maya/- Ketchi women felt this way. Women were asked, "How many months old do you think it is best for a child to be before another child is born?" In general, the vast majority of women (95 percent) stated that two or more years is the ideal interval between children, with 60 percent stating that three or more years is an ideal interval (Table 4-5). Fourteen percent of the Maya/Ketchi did not express an opinion on the ideal interval be- tween children. Respondents were asked, "Who should decide whether a person should use a method of contraception?" For this question, only 49 percent stated that both the man and woman should decide together, while 31 percent stated that the woman should decide, and 8 percent the man (Table 4-6). While rural women and ever-married women were more likely to state that the decision to use contraception is the responsibility of both the man and woman, urban women and never-married women were more likely to state that the responsibility is solely that of the woman. The proportion of women who felt that the woman should decide increases as level of education increases (Table 4-7). Also, from one third to one half of women who were not legally married at the time of the survey felt that it is the woman who should decide whether contraception is used (data not shown). In contrast, only 21 percent of legally married women felt that the woman should decide. While approximately 43 percent of Creoles and Garifunas felt that the woman should decide (Table 4-8), only 17 percent of the Maya/Ketchi women, 20 percent of Mestizo women, and 20 percent of women with less than 8 years of schooling felt that the woman should decide. Tables 4-9 and 4-10 show that nearly two thirds of all women aged 15-44 stated that financial pressures was the main reason a woman might want to limit the number of children that she has. A higher percentage of urban women (68 percent) than rural woman (60 percent) gave this reason. While approxi- mately two thirds of Creoles, Mestizos, and Garifunas cited this reason, only 50 percent of the Maya/Ketchi felt that this was the main reason a woman might want to limit family size. However, almost one in five Maya/- Ketchi women did not give a reason for limit- ing children. Child care problems were cited by an additional 7 percent of the women. This reason was more important for rural women than for urban women and was particularly important for the Maya/Ketchi as 15 percent of these women gave this reason. Interestingly, the proportion of women citing child care problems did not increase with number of living children (data not shown). Other rea- sons given included health of the mother (7 percent), work (4 percent), health of the child (4 percent), and schooling (3 percent). Table 4-1 Belize: Mean Perception of Ideal Family Size and Mean Actual Number of Living Children, by Selected Characteristics: Women Aged 15-44 Who Have Living Children 1991 Family Health Survey Selected Characteristics Ideal Family Size No. of Living Children Difference Actual-Ideal No. of Cases* (Unweighted) Total Residence Urban Rural Age 15-19 20-24 25-29 30-34 35-39 40-44 Years of Education 0-7 8 9+ Marital Status Ever Married Never Married Religion Protestant Catholic Other Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other 3.4 3.2 4.0 3.2 3.2 3.3 3.4 3.5 3.9 3.7 3.5 3.0 3.5 2.7 3.3 3.5 3.5 3.1 3.5 3.5 4.5 3.1 3.5 3.2 4.1 1.3 2.1 3.0 4.0 4.8 5.6 4.1 3.7 2.6 3.7 1.8 3.5 3.5 3.4 3.2 3.7 3.4 4.2 3.2 +0.1 0.0 +0.1 -1.9 -1.1 -0.3 +0.6 +1.3 +1.7 +0.4 +0.2 -0.4 +0.2 -0.9 +0.2 0.0 -0.1 +0.1 +0.2 -0.1 -0.3 +0.1 (1,729) (1,175) (554) (101) (343) (470) (397) (229) (189) (564) (646) (519) (1,572) (157) (657) (954) (118) (579) (765) (162) (111) (112) *For the purpose of calculating ideal family size, those who answered "Don't Know" or "God's Will" were omitted, for a total of 232 cases. Table 4-2 Belize: Mean Perception of Ideal Family Size, by Selected Characteristics: Women Aged 15-44 Who Do Not Have Any Living Children 1991 Family Health Survey Selected Characteristics Ideal Family Size No. of Cases* (Unweighted) Total Residence Urban Rural Age 15-19 20-24 25-29 30-44 Years of Education 0-7 8 9+ Marital Status Ever Married Never Married Religion Protestant Catholic Other Ethnic Group Creole Mestizo Maya/Ketchi Other 2.9 2.7 3.3 2.9 2.9 2.7 3.0 3.1 3.1 2.8 3.0 2.9 2.7 3.1 2.8 2.6 3.1 3.9 3.2 (596) (440) (156) (336) (145) (65) (50) (86) (157) (353) (135) (461) (250) (320) (26) (271) (223) (27) (75) *For the purpose of calculating the mean, those who answered "Don't Know" or "God's Will" were omitted, for a total of 98 cases. Table 4-3 Belize: Who Should Decide the Number of Children a Couple Wants to Have, by Residence: Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Residence Who Should Decide Total Urban Rural Both Wife/Woman Husband/Partner Fate, Up to God Other Total 65.9 21.0 7.8 4.4 1.0 100.0 64.9 25.3 7.2 1.8 0.8 100.0 67.7 12.4 9.0 9.5 1.3 100.0 No. of Cases (Unweighted) (2,656) (1,724) (932) Table 4-4 Belize: Who Should Decide the Number of Children a Couple Wants to Have, by Ethnic Group*: Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Ethnic Group Who Should Decide Total Creole Mestizo Garifuna Maya/ Ketchi Other Both Wife/Woman Husband/Partner Fate, Up to God Other Total 65.9 21.0 7.8 4.4 1.0 100.0 59.3 31.9 5.7 2.1 1.0 100.0 73.9 12.5 8.5 4.6 0.6 100.0 57.6 30.7 9.6 1.9 0.3 100.0 60.3 8.4 10.5 17.1 3.8 100.0 64.9 21.1 9.2 3.4 1.6 100.0 No. of Cases (Unweighted) (2,656) (894) (1,162) (228) (220) (151) *Excludes one case for whom ethnic group is unknown. Table 4-5 Belize: Perception of Ideal Time Interval Between Children, by Selected Characteristics: Women Aged 15-44 (Percent Distribution) 1991 Family Health Survey Number of Years Selected Characteristics <2 2<3 3<4 >4 Don't Know Total No. of Cases (Unweighted) Total Residence Urban Rural Years of Education 0-7 8 9+ Ethnic Group* Creole Mestizo Garifuna Maya/Ketchi Other Contraceptive Use Currently Using Not Using 4.8 4.7 5.0 6.4 3.8 4.4 4.9 4.7 4.9 3.5 6.5 5.0 4.7 28.4 25.7 33.8 31.7 29.1 25.2 22.5 31.2 31.9 35.5 28.7 28.5 28.4 31.4 32.5 29.1 30.5 32.7 31.0 28.4 33.9 30.3 27.9 37.8 31.3 31.5 28.8 31.5 23.5 22.9 28.2 34.1 37.3 23.9 30.3 19.2 23.8 32.6 26.9 6.5 5.5 8.6 8.5 6.2 5.3 6.8 6.2 2.5 13.9 3.2 2.6 8.5 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (2,656) (1,724) (932) (827) (918) (911) (894) (1,162) (228) (220) (151) (1,001) (1,655) *Excludes one case for whom ethnic group is unknown. Table 4-6 Belize: Who Should Decide Whether a Person Should Use a Method of Contraception, by Residence and Marital Status: Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Residence Marital Status Decision Maker Total Urban Rural Ever Married Never Married Both Wife/Woman Husband/Partner Doctor/Nurse Doesn't Believe in Contraception Other/Don't Know Total 48.7 30.8 8.3 5.4 0.9 5.9 100.0 44.5 38.4 6.7 5.7 0.6 4.1 100.0 57.0 15.6 11.7 4.7 1.6 9.5 100.0 52.9 28.4 9.5 5.1 1.1 3.0 100.0 41.1 35.0 6.2 5.9 0.7 11.2 100.0 No. of Cases (Unweighted) (2,656) (1,724) (932) (941) (715) Table 4-7 Belize: Who Should Decide Whether a Person Should Use a Method of Contraception, by Education: Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Years of Education Decision Maker Total 0-7 8 9+ Both Wife/Woman Husband/Partner Doctor/Nurse Doesn't Believe in Contraception Other/Don't Know Total 48.7 30.8 8.3 5.4 0.9 5.9 100.0 52.6 20.8 14.3 2.6 1.6 8.1 100.0 48.0 31.3 8.8 4.6 0.7 6.7 100.0 46.1 38.2 3.1 8.3 0.7 3.6 100.0 No. of Cases (Unweighted) (2,656) (827) (918) (911) Table 4-8 Belize: Who Should Decide Whether a Person Should Use a Method of Contraception, by Ethnic Group: Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Ethnic Group Decision Maker Total Creole Mestizo Garifuna Maya/ Ketchi Other Both Wife/Woman Husband/Partner Doctor/Nurse Doesn't Believe in Contraception Other/Don't Know Total 48.7 30.8 8.3 5.4 0.9 5.9 100.0 38.9 43.4 6.0 7.5 0.5 3.7 100.0 59.8 20.5 9.2 3.7 1.0 5.8 100.0 36.2 42.1 8.1 6.5 1.2 5.9 100.0 44.6 17.4 13.6 4.2 2.4 17.8 100.0 48.7 31.3 9.7 4.9 0.5 4.9 100.0 No. of Cases (Unweighted) (2,656) (894) (1,162) (228) (220) (151) Table 4-9 Belize: Percent Distribution of Reasons a Woman May Wish to Limit the Number of Children She Has, by Residence 1991 Family Health Survey Residence Reasons Total Urban Rural Financial Child Care Problems Health of Mother Work Related Health of Child Schooling Other Don't Know Total 65.4 7.2 6.5 4.3 3.7 3.5 1.3 8.2 100.0 68.2 6.0 5.9 5.1 2.4 4.3 1.4 6.7 100.0 59.8 9.5 7.6 2.6 6.2 1.8 1.1 11.4 100.0 No. of Cases (Unweighted) (2,656) (1,724) (932) Table 4-10 Belize: Percent Distribution of Reasons a Woman May Wish to Limit the Number of Children She Has, by Ethnic Group* 1991 Family Health Survey Ethnic Group Reasons Total Creole Mestizo Garifuna Maya/ Ketchi Other Financial Child Care Problems Health of Mother Work Related Health of Child Schooling Other Don't Know Total 65.4 7.2 6.5 4.3 3.7 3.5 1.3 8.2 100.0 64.6 6.3 6.8 3.5 5.4 5.3 1.4 6.6 100.0 68.3 7.0 5.9 3.5 3.3 2.8 1.1 8.1 100.0 64.7 6.5 8.4 3.4 6.5 3.4 0.9 6.2 100.0 49.8 15.0 5.9 6.3 2.8 0.0 1.4 18.8 100.0 70.8 4.3 7.0 2.7 3.2 2.2 2.2 7.6 100.0 No. of Cases (Unweighted) (2,656) (894) (1,162) (228) (220) (151) *Excludes one case for whom ethnic group is unknown. 21 5. Knowledge, Use, and Source of Contraception This chapter covers a wide range of topics concerning contraceptive methods: knowledge of contraceptive methods, knowledge of the fertile period, current contraceptive use, source of contraception, and reasons for non- use of contraception and desire to use in the future. 5.1 Knowledge of Contraceptive Methods All women aged 15-44 were asked if they had ever heard of various contraceptive methods. The findings of the survey show that knowl- edge of contraception in Belize is very high, as 95 percent of women 15-44 years of age have knowledge of at least one modern method of contraception (excludes diaphragms, rhythm, Billings, and withdrawal). Knowledge of at least one method was slightly higher in urban areas (97 percent) than in rural areas (92 percent) and ranged from 86 percent among women with no formal education to 100 per- cent among women with a post-secondary education. Knowledge of at least one modern method also varied according to ethnic group: Almost 100 percent of the Garifuna had knowl- edge of at least one modern method while only 88 percent of the Maya/Ketchi possessed this level of knowledge. There was wide variation in knowledge of individual methods (Table 5-1, Figure 5-1). For all women aged 15-44 the most widely known methods of contraception were oral contraceptives (93 percent), female sterilization (88 percent), injectables (86 percent), and condoms (82 percent). The least well known methods included vaginal creams, jellies, and foam (40 percent), the diaphragm (39 percent), withdrawal (35 percent), and the Billings method (16 percent). Table 5-1 also shows that, with the exception of the Billings method, rural women are less familiar with the individ- ual contraceptive methods than urban women. Knowledge of contraception was directly associated with the educational attainment of the respondents (Table 5-2). For example, while over 90 percent of women with a post- secondary education knew of oral contracep- tives, female sterilization, injectables, con- doms, IUDs, and the rhythm method, knowl- edge of these same methods among women with no formal education varied from 29 percent to 77 percent. Table 5-3 shows that knowledge of contracep- tive methods is relatively high for all ethnic groups except the Maya/Ketchi. Although the Maya/Ketchi have less knowledge of individual methods, from 70 percent to 82 percent report- ed knowledge of the more effective methods such as oral contraceptives, female steriliza- tion, and injectables. In households where Maya is the principal language spoken, knowl- edge of individual methods was found to be relatively low (Table 5-4). Among women living in households where Maya is the prince- pal language, there is not one method that at least two thirds of these women have heard of. At present, most of the family planning litera- ture that is available in Belize is printed only in English and very few publications exist in Spanish and none in indigenous or other local languages. These findings indicate the need to develop educational materials specifically for those who do not speak English. 5.2 Knowledge of the Fertile Period A basic understanding of the ovulatory cycle and an awareness of the fertile period is impor- tant for practicing certain family planning methods, such as rhythm, the Billings method, and withdrawal. As noted earlier, 53 percent of all women aged 15-44 said that they had knowledge of the rhythm method, while only 35 percent and 16 percent, respectively, stated that they had knowledge of withdrawal and the 22 Billings method, respectively. According to the findings of this survey, although only 5 percent of users practice periodic abstinence, rhythm or Billings is the fourth most used method in Belize. All respondents were asked, "During a wo- man's menstrual cycle, when is it most likely that she will become pregnant?" Only 23 percent of all respondents correctly identified the middle of the cycle as the time a woman is most likely to get pregnant (Table 5-5). A higher percentage (36 percent) of ever-users of rhythm, the Billings method, or withdrawal had correct knowledge of when a woman is most likely to get pregnant during her menstru- al cycle. Among all respondents, urban wom- en, women with nine or more years of school- ling, women aged 40-44, and Creoles were the most likely to possess correct knowledge of the safe period. The same differentials exist among ever-users of natural methods and withdrawal, except that Garifunas rather than Creoles were the most likely to possess correct knowledge of the safe period. The biological aspects of reproduction are taught in secondary schools in Belize but other aspects of sex education are not part of the curriculum. Churches and young adult clubs sometimes address these issues, but their audiences are limited and their treatment of the subject matter is superficial. Rarely is sex education dealt with in the home. Thus, it is not surprising that less than a quarter of the respondents know when a woman would most likely get pregnant during the menstrual cycle. 5.3 Current Contraceptive Use This section covers contraceptive use according to sociodemographic variables typically asso- ciated with use: marital status, residence, age, number of living children, education, socioe- conomic status (measured by number of ameni- ties found in the household), and work status. In addition, use is examined by ethnic group, principal language spoken in the household, and religion. With the exception of the first table (Table 5-6), the results presented here focus on the level of use found among women currently married or living in consensual unions who are 15-44 years of age. In the text and tables that follow, these women are re- ferred to collectively as "married women." Overall, one third of all women aged 15-44 were found to be using contraceptive methods at the time of the survey (Table 5-6). The prevalence of contraceptive use varied from 49 percent among women in a visiting partner relationship to 7 percent among never married women (a visiting partner relationship is de- fined as two individuals who do not live in the same house but have a sexual relationship in which one partner visits the other on a more or less regular basis). Forty-seven percent of married women reported using a method. The two most prevalent methods used by ever- married women are female sterilization and oral contraceptives, while the most prevalent method used by women with a visiting partner and never-married women is oral contracep- tives. As shown in Table 5-7, urban areas of the country have a much higher contraceptive prevalence rate with 55 percent of married women reporting current use, compared to 33 percent of married women living in rural areas. As in neighboring countries, the most prevalent method used by married women in Belize is female sterilization, which accounts for 40 percent of all contraceptive use (Figure 5-2). The second most prevalent method is oral contraceptives, accounting for 32 percent of overall use, followed by injectables, which account for an additional 9 percent of total use. Thus, three methods, all with very high effect- tiveness, account for 81 percent of overall use. Use of the remaining methods shown in Table 5-7 and Figure 5-3 is relatively low. Table 5-8 shows that as age increases so does the prevalence of contraceptive use. Use is lowest for married women 15-19 (26 percent), 23 but increases to 37 percent among those 20-24 years old. By the time married women are 30 years of age or older, more than 50 percent are using some form of contraception. Oral con- traceptives are the most used method among married women 15-29 years of age, but after age 30 the most prevalent method is female sterilization. An illustration of the increasing prevalence of female sterilization as women age is that this method accounts for only 7 percent of total use among married women 20- 24 years of age, compared with 46 percent among women 30-34, and 76 percent among women 40-44. There was one married woman in the age group 15-19 who reported having a tubal ligation. She is a 19 year old woman who has four living children. She reported that the ideal number of children to have is four and that she is satisfied with the operation. Table 5-9 and Figure 5-3 show the relationship between use and number of living children. Because of the high correlation between age and number of children, these results show a similar pattern to that presented in the previous table. Overall, contraceptive use is relatively low among married women with no living children (14 percent) but increases rapidly to 34 percent after women have their first child and to over 50 percent after the second child. Female sterilization is the most used method after the third child, while oral contraceptives, injectables, and natural family planning (rhythm and the Billings method) are important for women with one to three children. In general, the use of reversible methods declines in importance with an increase in number of living children, from a high of 80 percent among currently using women with two chil- dren to 41 percent among current users with 6 or more living children, as an increasing percentage of women rely on sterilization. The one married woman with no living chil- dren who has had a tubal ligation has never been pregnant. She is currently 41 years of age and was sterilized when she was 27. She reported that she was satisfied with having had the operation. As expected, use of contraceptive methods was also found to be directly associated with educa- tional attainment (Table 5-10, Figure 5-4). This is due in part to the greater use of re- versible methods, especially oral contracep- tives, as the level of education increases. For example, women with a post-secondary educa- tion were 6 times more likely to use oral contraceptives than women with no formal education. Contraceptive use also increases with the reported number of household amenities (a surrogate of socioeconomic status, Table 5-11). Prevalence of use in the highest category (8 to 10 amenities) is twice that found in the lowest category (0 to 2 amenities). The differential is primarily explained by the greater use of oral contraceptives and female sterilization among women living in households with the highest number of household amenities. Whether or not a woman is in the labor force is an important factor associated with the use of contraception, as shown in Table 5-12. Almost two thirds of working married women were found to be using contraception compared with 42 percent of nonworking women. Use of oral contraceptives varied according to work status, as two times as many working women were found to be using this method than non- working women. Similarly, working women were more likely to report sterilization as their method than nonworking women. Differences in contraceptive prevalence are also seen according to ethnic group (Table 5-13, Figure 5-5) and principal language spoken in the household (Table 5-14). Creole women reported the highest prevalence (53 percent) while the Maya/Ketchi women reporte- d the lowest prevalence (25 percent). Al- though there was very little difference in the use of surgical contraception by Creoles, 24 Mestizos, and Garifunas (about 20 percent), approximately two times as many Creoles reported using oral contraceptives as Garifunas and Mestizos. According to principal language spoken in the household, the highest preva- lence of contraceptive use was reported by married women living in households where English is the principal language (Table 5-14). Conversely, the lowest prevalence was report- ed by married women who live in households where Maya is the principal language (10 percent). However, this prevalence is twice the level found in this same ethnic group in Guatemala (Ministerio de Salud Pública y Asistencia Social, 1989). Other groups speak- ing Creole, Garifuna, and Spanish range from 54 to 43 percent prevalence. As Table 5-15 shows, very little difference in the use of contraception exists between Protes- tants and Catholics. Interestingly, about the same percentage of Protestants and Catholics reported using each method, including natural family planning. Contraceptive prevalence by residence is shown in Figure 5-6. The differences in contraceptive prevalence according to residence persist despite controlling for age, years of education, number of household amenities, number of living children, and work status (Table 5-16). For example, use is higher in urban areas than in rural areas for all age groups. Urban married women aged 15-19 were 4 times as likely to report current use than their rural counterparts. Similarly, use is higher for all education groups in urban areas relative to rural areas. It should be noted that similar patterns of use exist among women with 9 or more years of formal education, regardless of residence. For both urban and rural areas, use increases as number of living children increases. However, use levels off to about 35 percent in rural areas after the second child is born compared to over 60 percent among urban mothers. Nearly 1.7 times as many nonworking urban women reported current use than nonworking rural women. However, no significant difference is found to exist among working women in both strata. In general, the positive association between contraceptive use and education is maintained when age, number of living children, number of household amenities, and work status are controlled, as shown in Table 5-17 and Figures 5-7 and 5-8. That is, women with higher levels of education are more likely to use contraception than women with lower levels of education. For certain groups with 9 or more years of formal education, contraceptive use reaches impressively high levels. This is true for women with 2 to 5 living children and women living in households with 8 to 10 amenities. It should be noted that contracep- tive use among women with 8 years of school- ing is similar in some instances to that of women with 9 or more years of schooling, i.e., among women 35-44 years of age, wom- en with 6 or more children, women with 8-10 household amenities, and working women. Earlier in this report, planning status of last pregnancy was discussed. Table 5-18 shows contraceptive use according to this variable. A higher percentage of married women aged 15- 44 whose last pregnancy within five years of interview was unwanted were using a contra- ceptive method than married women who reported that their last pregnancy was either mistimed or planned. Of those women with an unwanted pregnancy who reported contracep- tive use, 47 percent were using sterilization as their current method and an additional 39 percent were either using oral contraceptives or injectables. Thus, overall, 86 percent of women whose last pregnancy was unwanted and who were using contraception were using the most effective methods. Nonusers of contraception following an unwanted birth tend to be older and of higher parity, which sug- gests that they may have always had difficulty in regulating their fertility. For women who reported that their last pregnancy was planned or mistimed and were using contraception, 72 25 percent and 88 percent, respectively, were using reversible methods. Reasons for Currently Using Contraception All current users of contraception were asked whether they were using in order to space or to limit births. Two thirds of contracepting married women aged 15-44 responded that they were using contraception to limit child- bearing while the remaining one third stated that they wanted to space their pregnancies (Table 5-19). There were no differences in reasons for using between urban and rural areas. However, as expected, the percentage of current users wanting to limit childbearing increases with age and number of living chil- dren of the respondent: by the time these women are 25-29 years of age and/or have three living children, over half want to limit their childbearing. It is noteworthy that 45 percent of current users of the rhythm/Billings methods, vaginal methods, and withdrawal (collapsed into "other") and 50 percent of condom users were using to limit childbearing. Finally, with the data presented in Table 5-19, a profile is given of the women who are using contraception to space their pregnancies. As expected, these women tend to be young (15- 24 years of age), have attained a higher level of education, and have fewer than two living children. Characteristics at First Contraceptive Use The time at which a woman begins to use contraception in her reproductive years is an important factor in how much her fertility will be reduced by using contraception. A woman who begins at a later age or after having many children will probably avert fewer unintended births than a woman who begins at a younger age and with fewer children. Table 5-20 shows that mean age and mean number of living children of ever-users of contraception at the time of first contraceptive use is 27.9 years of age and 3.8 living chil- dren. Mean age is 27.3 years for urban wom- en and 29.9 years for among rural women. The largest age differential is between Protes- tants (22.6 years) and Catholics (28.6 years). There is an inverse relationship with education and number of household amenities. With respect to ethnicity, the Creoles stand out as having a relatively young age at first use (25 years). There is considerable variation in number of living children at first use according to each of the background variables shown in the table and is in the same direction as mean age. Mestizos have twice as many children (5.0) as Creoles (2.5) at first use, and Catholics have 4.5 children on the average compared with 3.0 for Protestants. With few exceptions, approxi- mately one half of users did not initiate contra- ception until they had 3 children. An analysis of the number of living children that ever-married women had at the time of first contraceptive use according to their cur- rent age reveals that younger cohorts of wom- en are initiating contraceptive use earlier than older cohorts did. As Table 5-21 shows, only 8 to 9 percent of women who are currently 35- 44 years of age began using contraception before their first child compared to 19 to 21 percent of women currently aged 15-24. In general, as the current age of the respondents decreases, the proportion initiating contracep- tion at lower parities increases. Contraceptive Prevalence in the Region The data appearing in Table 5-22 place contra- ceptive prevalence in Belize in a geographic perspective by comparing the 1991 results with recent survey results from other countries in the region. Contraceptive prevalence in Costa Rica (69 percent) is the highest of any of the countries, while Guatemala (23 percent) has the lowest prevalence of the countries recently surveyed in the region. Belize's prevalence is essentially the same as that of El Salvador. With the exception of Costa Rica, Jamaica, 26 and Trinidad and Tobago, the most prevalent method in each of the countries is female sterilization. With the exception of Mexico, the second most used method in the region is oral contraceptives. In Honduras, there is no difference in prevalence between female steril- ization and oral contraceptives. Compared to other countries in the region, Belize is third, along with Mexico, with regard to the use of female sterilization and also third with regard to the use of oral contraceptives. 5.4 Source of Contraception As shown in Table 5-23 and Figure 5-9, the most important sources of contraception in Belize in 1991 were Government health faci- lities (Ministry of Health) and pharmacies. The percentage of users that rely upon the Ministry of Health and private clinics did not vary appreciably by area of residence. In contrast, 1.6 times more urban users rely on pharmacies as their source of contraception than women living in rural areas. On the other hand, a higher proportion of rural than urban users rely on the Belize Family Life Association (BFLA), the International Planned Parenthood Federation (IPPF) affiliate in Belize, despite the fact that the BFLA offices are located in urban areas. A possible explanation for this is that the urban locations of the BFLA provide a sense of anonymity for rural women. Anoth- er possible explanation is that rural women elect to go to BFLA clinics because they are certain that they will receive the information and services they are seeking. Educational attainment appears to be an impor- tant determinant of where users obtain their method (Table 5-24). In general, women with higher educational attainment tend to use pharmacies and the BFLA as their sources of contraception while women with lower educa- tional attainment tend to rely on government health facilities. Use of private clinics does not vary appreciably by educational attainment. Although use of government health facilities did not vary much by ethnicity, use of the other sources of contraception did (Table 5- 25). A higher proportion of Garifuna (30.1 percent) rely upon the BFLA for contraceptives than any other ethnic group. Similarly, a higher proportion of Creoles rely on pharma- cies. Maya/Ketchi and Mestizos had higher proportions relying on private clinics as their source of contraception than did other ethnic groups. An analysis of source of contraception by method (Table 5-26) shows that the Ministry of Health is the principal source of female steril- ization in the country (87 percent). Only a small percentage of users of temporary meth- ods rely upon the Ministry of Health as their source of contraceptives. With respect to oral contraceptives and condoms, pharmacies are by far the major supplier of these methods (66 percent and 79 percent, respectively). The BFLA is the principal supplier of injectables and is second in importance with respect to oral contraceptives. IUDs are primarily insert- ed in private clinics (52 percent), followed by the Ministry of Health (24 percent), and the BFLA (19 percent). About 4 percent each of users of oral contraceptives and injectables obtain their supplies outside of Belize. It should be noted that the Ministry of Health has no definite family planning policy. Occa- sionally, the hospital may receive contracep- tives from donor agencies and distribute them. If a woman attending a clinic is perceived to be in need of family planning by the nurse or physician then she might be referred to the BFLA. Private doctors who perform steriliza- tions almost always use government facilities to do the operation. However, all of this depends on the medical attendants' initiative more than government rules. Thus, an un- known percentage of tubal ligations reported to be performed at government facilities were undoubtedly performed by private physicians. Officially, the Ministry of Health does not supply contraceptives. 27 5.5 Reasons for Nonuse of Contraception and Desire to Use in the Future In the 1991 Family Health Survey, nonusers were asked the reasons why they were not currently using contraception. This section covers the reasons given by the respondents and the relationship between the characteristics of nonusers and desire to use contraception in the future. Also, for women who want to use a method, the preferred source and method are discussed. Reasons for Nonuse Of married women aged 15-44 not using contraception at the time of the survey, 59 percent were not using any method for reasons related to pregnancy, subfecundity, or lack of sexual activity (Table 5-27). This includes 7 percent who were postpartum or breastfeeding. The other 41 percent of nonusers who gave "other reasons" for not using contraception may be considered potential candidates for adopting contraception. This percentage represents an estimated 4,230 married women aged 15-44. However, it should be noted that a sizeable proportion of the 59 percent of nonusers who are not immediate candidates for use (47 percent, or approximately 2,860 wom- en) are potential high priority target women following their current pregnancy and/or postpartum period. Among women who gave "other reasons," the major reasons for nonuse were fear of side effects (9 percent), "doesn't like or want contraception" (8 percent), and lack of knowl- edge of methods (8 percent). Less than one percent of women stated they were not using because of religious reasons. Examining reasons for nonuse by education, we observe in Table 5-28 that the proportion of women reporting a reason for nonuse relat- ed to pregnancy, subfecundity, or lack of sexual activity increases as the formal educa- tion of the women increases. Thus, the pro- portion of women who could be considered potential candidates for family planning at the time of the survey is inversely related to the level of education. Among lower educated women, major reasons for nonuse included lack of knowledge of methods, fear of side effects, and "doesn't like or want contracep- tion." Reasons for nonuse also varied by number of living children (data not shown). As expected, women of lower parities were not using prince- pally because of reasons related to pregnancy. As parity increased, so did the proportion of women giving "other reasons" for their nonuse of contraception. Thus, the proportion of women who could be considered candidates for family planning at the time of the survey is directly related to number of living children. The principal reasons for nonuse among higher parity women were the same as those reported by lower educated women. Reasons Discontinued the Use of Contraception Former users of contraception were asked why they discontinued the use of their most recent method. Overall, 40 percent of the married nonusers had previously used a contraceptive method. The principal methods used by these women were oral contraceptives (56 percent), injectables (14 percent), and condoms (9 per- cent). Almost one third of the women stated that their desire to become pregnant led them to discontinue use, while an additional 29 percent discontinued because they had or feared side effects from their method (Table 5- 29). The proportion citing side effects was highest among former users of oral contracep- tives and injectables. Thirty-one percent of former users of condoms stated that they discontinued the use of condoms because they "didn't like or want to use" this method. Similarly, an additional 12 percent of former users of condoms stated that the method was not effective. 28 Desire to Use Contraception in the Future Slightly greater than half (54 percent) of fe- cund nonusers said that they desired to use a method of contraception in the future (Table 5- 30). The proportion wanting to use in the future was highest among nonusers living in urban areas, among nonusers less than 30 years of age, among nonusers with fewer than four living children, among nonusers with nine or more years of schooling, and among non- users who are Creole or Garifuna. The right-hand panel of Table 5-30 shows that three quarters of nonusers who desire to use a method have knowledge of a source of contra- ception. Rural women, women 15-19 years of age, women with no living children, women with lower educational attainment, and the Maya/Ketchi were the least likely to know of a source of contraception. The top panel of Table 5-31 shows the meth- ods of choice mentioned by nonusers desiring to use a method. The most frequently desired methods were oral contraceptives, female sterilization, and injectables. Oral contracep- tives, female sterilization, and injectables were the methods of choice among urban nonusers, while injectables, female sterilization, and oral contraceptives were the methods of choice among rural nonusers, in that order. Pharmacies were cited as a potential source by 31 percent of nonusers and were a commonly mentioned source by urban nonusers. Govern- ment health facilities were cited as a potential source by more than a quarter of nonusers, and were the principal source mentioned by nonus- ers living in rural areas. Overall, the BFLA was the third most mentioned source, followed by private clinics. 29 30 31 32 33 34 Table 5-1 Belize: Percentage of All Women Aged 15-44 With Knowledge of Contraceptive Methods, by Method and Years of Education 1991 Family Health Survey Years of Education Contraceptive Method Total None 1-7 8 9-12 13+ Orals Female Sterilization Injection Condoms IUD Rhythm Male Sterilization Vaginal Tablets Other Vaginal Methods* Diaphragm Withdrawal Billings 93.1 87.7 85.8 81.7 71.4 53.3 49.7 46.1 39.6 38.7 34.5 16.0 77.0 74.8 69.1 48.9 42.5 29.5 39.6 25.2 17.3 23.7 18.0 9.3 88.5 79.5 82.9 63.2 60.1 36.6 44.4 31.7 23.0 20.8 24.3 10.3 93.0 88.2 87.3 84.4 71.6 50.1 45.1 42.4 35.2 29.5 29.3 13.8 97.7 92.8 86.9 94.7 79.1 64.7 53.2 57.5 51.9 56.2 42.0 17.7 100.0 100.0 93.1 98.2 92.7 92.0 79.7 78.6 79.3 79.7 72.8 42.7 No. of Cases (Unweighted) (2,656) (113) (714) (918) (713) (198) *Includes creams, jellies, and foam. Table 5-2 Belize: Percentage of All Women Aged 15-44 With Knowledge of Contraceptive Methods, by Method and Ethnic Group 1991 Family Health Survey Ethnic Group Contraceptive Method Total Creole Mestizo Garifuna Maya/ Ketchi Other* Orals Female Sterilization Injection Condoms IUD Rhythm Male Sterilization Vaginal Tablets Other Vaginal Methods** Diaphragm Withdrawal Billings 93.1 87.7 85.8 81.7 71.4 53.3 49.7 46.1 39.6 38.7 34.5 16.0 95.7 91.6 85.3 94.1 79.5 59.9 50.2 59.0 51.4 48.4 41.7 17.9 91.8 85.8 86.4 74.9 65.5 50.8 49.9 36.9 31.2 30.4 29.5 14.4 97.8 96.3 92.5 94.1 87.9 55.1 48.9 57.0 47.4 51.7 39.3 16.4 81.9 70.0 78.0 49.8 45.6 30.0 38.0 24.0 17.8 18.8 15.7 11.9 96.2 89.7 83.2 82.2 76.8 62.2 63.2 50.8 49.7 49.2 48.7 22.2 No. of Cases*** (Unweighted) (2,656) (894) (1,162) (228) (220) (151) *Primarily includes East Indians, Asians, and those of European Ancestry. **Includes creams, jellies, and foam. ***Excludes one case for whom ethnic group is unknown. Table 5-3 Belize: Percentage of All Women Aged 15-44 With Knowledge of Contraceptive Methods, by Method and Language Spoken in Household 1991 Family Health Survey Language Contraceptive Method Total English Spanish Creole Garifuna Maya Other Orals Female Sterilization Injection Condoms IUD Rhythm Male Sterilization Vaginal Tablets Other Vaginal Methods* Diaphragm Withdrawal Billings 93.1 87.7 85.8 81.7 71.4 53.3 49.7 46.1 39.6 38.7 34.5 16.0 98.3 93.9 87.0 95.2 82.7 74.0 68.8 63.6 63.6 67.5 58.9 18.6 91.1 84.1 86.5 71.1 63.9 48.5 50.2 35.2 28.6 28.7 28.0 16.1 96.8 92.5 86.2 93.6 80.1 59.2 48.1 56.3 48.7 44.7 40.0 16.6 96.3 98.1 95.6 97.5 85.6 46.3 51.9 55.6 47.5 58.1 33.7 16.9 63.4 56.1 64.2 25.2 20.3 15.5 26.0 13.0 12.2 12.2 8.1 5.7 75.0 57.5 65.0 50.0 50.0 32.5 45.0 25.0 20.0 20.0 12.5 5.0 No. of Cases** (Unweighted) (2,656) (172) (1,130) (1,110) (117) (93) (33) *Includes creams, jellies, and foam. **Excludes one case for whom language spoken in household is unknown. Table 5-4 Belize: Percent of All Women Aged 15-44 and Women Who Have Ever Used Rhythm, Billings, or Withdrawal With Correct Knowledge of When During the Menstrual Cycle a Woman is Most Likely to Get Pregnant 1991 Family Health Survey Selected Characteristics All Respondents Ever Users of Rhythm, Billings or Withdrawal Total Residence Urban Rural Age 15-24 25-29 30-34 35-39 40-44 Marital Status Ever Married Never Married Years of Education 0-7 8 9+ Ethnic Group* Creole Mestizo Garifuna Other Contraceptive Use Currently Using Not Using 23.1 25.2 19.0 19.7 22.1 28.7 24.9 31.6 23.4 22.7 15.8 16.5 35.0 28.2 21.3 20.4 16.9 25.1 22.1 (2,656) (1,724) (932) (1,075) (593) (483) (280) (225) (1,941) (715) (827) (918) (911) (894) (1,162) (228) (371) (1,001) (1,655) 36.3 39.9 23.2 32.2 32.2 44.7 19.0 57.7 36.5 35.7 28.7 20.5 47.3 31.0 36.7 50.0 40.8 34.3 39.5 (347) (261) (86) (84) (93) (91) (48) (31) (296) (51) (66) (103) (178) (134) (137) (35) (41) (226) (121) *Excludes one case for whom ethnic group is unknown. Table 5-5 Belize: Percentage of All Women Aged 15-44 With Knowledge of Contraceptive Methods, by Method and Residence 1991 Family Health Survey Residence Contraceptive Method Total Urban Rural Orals Female Sterilization Injection Condoms IUD Rhythm Male Sterilization Vaginal Tablets Other Vaginal Methods* Diaphragm Withdrawal Billings 93.1 87.7 85.8 81.7 71.4 53.3 49.7 46.1 39.6 38.7 34.5 16.0 95.4 90.2 86.1 90.1 75.3 58.4 57.2 53.5 45.0 42.9 37.6 16.1 88.7 82.9 85.3 65.1 63.6 43.2 46.6 31.5 28.9 30.3 28.4 15.9 No. of Cases (Unweighted) (2,656) (1,724) (932) *Includes creams, jellies, and foam. Table 5-6 Belize: Percent Distribution of All Women Aged 15-44 Currently Using Contraceptives, by Method and Marital Status 1991 Family Health Survey Marital Status Current Use and Method Total Married/ In Union Sep./Div./ Widowed Visiting Partner Never Married Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 33.5 12.3 12.0 2.9 1.8 1.7 1.3 1.6 66.5 100.0 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 31.0 16.2 9.2 2.6 0.0 2.6 0.0 0.4 69.0 100.0 49.5 3.8 31.7 3.2 2.1 3.8 2.7 2.0 50.5 100.0 6.6 1.0 3.8 0.1 0.7 0.8 0.2 0.1 93.4 100.0 No. of Cases* (Unweighted) (2,656) (1,790) (151) (117) (598) *Excludes 4 cases for whom marital status is unknown. Table 5-7 Belize: Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method and Residence 1991 Family Health Survey Residence Current Use and Method Total Urban Rural Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 55.1 22.4 18.0 4.3 2.9 2.5 2.1 2.9 44.9 100.0 33.2 12.9 10.0 4.3 1.9 1.1 1.7 1.6 66.8 100.0 No. of Cases (Unweighted) (1,790) (1,077) (713) Table 5-8 Belize: Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method and Age 1991 Family Health Survey Age Contraceptive Method Total 15-19 20-24 25-29 30-34 35-39 40-44 Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 26.2 0.6 12.8 7.0 1.7 0.6 1.7 1.7 73.8 100.0 36.9 2.8 20.6 4.9 1.6 2.3 1.6 3.0 63.1 100.0 45.6 11.1 18.4 6.2 2.6 2.1 3.0 2.3 54.4 100.0 53.6 24.5 16.2 3.2 4.2 1.9 1.4 2.3 46.4 100.0 54.8 33.3 9.3 2.9 2.6 2.6 2.9 1.3 45.2 100.0 56.3 43.0 5.2 1.4 1.7 1.4 0.3 3.1 43.7 100.0 No. of Cases (Unweighted) (1,790) (124) (359) (486) (395) (239) (187) Table 5-9 Belize: Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method and Number of Living Children 1991 Family Health Survey No. of Living Children Current Use and Method Total 0 1 2 3 4 5 6+ Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 14.3 0.6 8.0 0.0 2.9 1.2 1.1 0.6 85.7 100.0 34.3 2.3 19.0 4.7 2.0 1.7 1.0 3.7 65.7 100.0 53.3 10.9 25.1 5.6 2.9 2.7 4.3 1.9 46.7 100.0 50.5 19.3 15.7 5.0 3.3 1.7 2.5 3.0 49.5 100.0 54.1 30.7 14.1 2.1 2.8 2.8 0.7 0.7 45.9 100.0 56.6 30.8 12.7 5.9 1.8 1.4 2.7 1.4 43.4 100.0 49.3 29.2 7.1 4.7 2.0 1.8 0.9 3.6 50.7 100.0 No. of Cases (Unweighted) (1,790) (137) (234) (333) (319) (237) (198) (332) Table 5-10 Belize: Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method and Years of Education 1991 Family Health Survey Years of Education Current Use and Method Total None 1-7 8 9-12 13+ Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 40.0 23.2 4.0 4.0 1.6 0.0 0.8 6.4 60.0 100.0 38.8 14.5 12.7 4.3 1.9 1.3 1.3 2.0 61.2 100.0 49.2 24.5 10.8 5.3 2.0 2.4 2.0 2.0 50.8 100.0 55.0 13.2 26.1 3.1 5.0 3.1 2.9 1.7 45.0 100.0 58.8 19.9 25.9 2.3 2.3 0.8 3.0 4.6 41.2 100.0 No. of Cases (Unweighted) (1,790) (104) (575) (645) (358) (108) Table 5-11 Belize: Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method and Number of Household Amenities 1991 Family Health Survey No. of Household Amenities Current Use and Method Total 0-2 3-7 8-10 Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 29.7 11.1 8.3 4.3 1.8 1.2 1.1 2.0 70.3 100.0 50.2 22.1 14.5 5.5 2.6 1.5 1.9 1.9 49.8 100.0 62.5 21.9 24.7 1.7 3.4 3.8 3.2 3.8 37.5 100.0 No. of Cases (Unweighted) (1,790) (574) (846) (370) Table 5-12 Belize: Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method and Work Status 1991 Family Health Survey Work Status Current Use and Method Total Not Working Working Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 41.9 16.9 12.1 4.4 2.5 1.7 1.4 2.8 58.1 100.0 62.4 24.8 23.8 4.0 2.6 2.8 3.6 0.8 37.6 100.0 No. of Cases (Unweighted)* (1,790) (1,374) (414) *Excludes 2 cases for whom work status is not known. Table 5-13 Belize: Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method and Ethnic Group 1991 Family Health Survey Ethnic Group Current Use and Method Total Creole Garifuna Mestizo Maya/ Ketchi Other Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 53.3 18.8 21.0 4.0 2.8 2.6 2.1 2.1 46.7 100.0 49.4 19.6 10.1 7.7 3.0 3.6 3.6 1.8 50.6 100.0 46.0 20.2 13.0 4.5 2.7 1.3 1.8 2.6 54.0 100.0 24.5 8.0 9.0 3.0 0.5 1.0 2.0 1.0 75.5 100.0 53.3 21.5 18.5 1.5 3.0 3.7 0.7 4.4 46.7 100.0 No. of Cases* (Unweighted) (1,790) (474) (137) (890) (171) (117) *Excludes one case for whom ethnic group is unknown. Table 5-14 Belize: Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method and Language Spoken In Household 1991 Family Health Survey Language Spoken in Household Current Use and Method Total English Creole Garifuna Spanish Maya Other Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 61.8 24.5 23.6 2.7 2.7 0.9 0.0 7.3 38.2 100.0 54.4 21.0 19.1 3.8 2.8 3.0 2.8 1.8 45.6 100.0 43.2 17.3 8.6 8.6 3.7 1.2 2.5 1.2 56.8 100.0 42.8 17.8 12.6 4.6 2.4 1.1 1.7 2.6 57.2 100.0 10.1 4.3 2.9 2.9 0.0 0.0 0.0 0.0 89.9 100.0 25.0 6.3 0.0 3.1 3.1 12.5 0.0 0.0 75.0 100.0 No. of Cases* (Unweighted) (1,790) (97) (648) (69) (884) (63) (28) *Excludes one case for whom language spoken at home is unknown. Table 5-15 Belize: Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method and Religion 1991 Family Health Survey Religion Current Use and Method Total Protestant Catholic Other* Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 46.7 18.7 14.9 4.3 2.5 1.9 1.9 2.4 53.3 100.0 49.6 18.3 17.4 4.1 2.8 2.4 1.7 2.9 50.4 100.0 45.9 19.2 14.2 4.3 2.6 1.5 2.1 2.0 54.1 100.0 37.5 17.1 7.2 5.3 0.7 2.6 2.0 2.6 62.5 100.0 No. of Cases (Unweighted) (1,790) (655) (1,010) (125) *Primarily includes those who profess not to practice any religion. Table 5-16 Belize: Percentage of Currently Married Women Aged 15-44 Currently Using Contraception, by Selected Characteristics and Residence 1991 Family Health Survey Residence Selected Characteristics Total Urban Rural Total Age 15-19 20-24 25-29 30-34 35-39 40-44 Years of Education 0-7 8 9+ No. of Household Amenities 0-2 3-7 8-10 No. of Living Children 0 1 2 3 4 5 6+ Work Status* Not Working Working 46.7 26.2 36.9 45.6 53.6 54.8 56.1 38.2 49.2 55.9 29.7 50.2 62.5 14.3 34.3 53.3 50.5 54.1 56.6 49.3 41.9 62.4 (1,790) (124) (359) (486) (395) (239) (187) (679) (645) (466) (574) (846) (370) (137) (234) (333) (319) (237) (198) (332) (1,374) (414) 55.1 47.2 42.0 50.6 62.6 64.9 62.7 51.6 56.2 56.4 36.8 53.6 61.7 20.0 38.9 61.2 58.9 63.5 65.5 63.3 51.3 62.9 (1,077) (53) (207) (297) (248) (150) (122) (297) (371) (409) (91) (634) (352) (92) (154) (223) (202) (149) (118) (139) (730) (347) 33.2 11.0 28.9 36.8 38.1 38.8 43.0 27.0 38.5 52.2 28.4 40.4 ** 3.3 25.5 35.9 33.9 35.1 41.5 38.9 30.6 59.7 (713) (71) (152) (189) (147) (89) (65) (382) (274) (57) (483) (212) (18) (45) (80) (110) (117) (88) (80) (193) (644) (67) *Excludes two cases for whom work status is unknown. **Less than 25 cases. Table 5-17 Belize: Percentage of Currently Married Women Aged 15-44 Currently Using Contraception, by Selected Characteristics and Years of Education 1991 Family Health Survey Years of Education Selected Characteristics Total 0-7 8 9+ Total Age 15-19 20-24 25-29 30-34 35-39 40-44 No. of Living Children 0 1 2 3 4 5 6+ No. Household Amenities 0-2 3-7 8-10 Work Status* Not Working Working 46.7 26.2 36.9 45.6 53.6 54.8 56.3 14.3 34.3 53.3 50.5 54.1 56.6 49.3 29.7 50.2 62.5 41.9 62.4 (1,790) (124) (359) (486) (395) (239) (187) (137) (234) (333) (319) (237) (198) (332) (574) (846) (370) (1,374) (414) 38.2 20.4 32.3 35.9 43.5 44.3 52.6 8.6 25.3 36.8 39.1 41.3 47.8 45.3 27.8 48.5 52.5 35.7 61.5 (679) (72) (133) (186) (124) (89) (75) (40) (64) (115) (120) (83) (83) (174) (369) (270) (40) (615) (63) 49.2 31.3 31.9 45.1 55.6 63.5 58.2 9.6 32.7 54.8 51.2 56.3 60.0 54.1 31.0 54.3 61.2 45.1 65.6 (645) (34) (117) (165) (156) (96) (77) (44) (74) (109) (108) (104) (79) (127) (190) (347) (108) (523) (121) 55.9 ** 47.7 58.9 61.9 57.8 60.0 23.1 42.0 71.3 64.7 67.7 68.3 52.4 ** 46.0 65.3 51.4 60.7 (466) (18) (109) (135) (115) (54) (35) (53) (96) (109) (91) (50) (36) (31) (15) (229) (222) (236) (230) *Excludes two cases for whom work status is unknown. **Less than 25 cases. NOTE: Figures in parentheses are unweighted numbers of cases. Table 5-18 Belize: Percent Distribution of Currently Married Women Aged 15-44 Who Had a Pregnancy in the Last 5 Years and Who Are Currently Using Contraceptives, by Method and Planning Status of Last Pregnancy 1991 Family Health Survey Planning Status Current Use and Method Total Planned Mistimed Unwanted Unknown Currently Using Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 42.3 11.4 16.9 5.8 2.1 1.7 1.9 2.5 57.7 100.0 40.3 11.1 16.5 5.3 2.1 1.7 2.1 1.5 59.7 100.0 43.9 5.3 21.0 6.3 2.1 2.1 2.1 5.0 56.1 100.0 50.0 23.7 11.9 7.7 1.5 2.1 0.5 2.6 50.0 100.0 43.1 5.9 19.6 5.9 3.9 0.0 3.9 3.9 56.9 100.0 No. of Cases (Unweighted) (1,274) (839) (238) (154) (43) Table 5-19 Belize: Percent Distribution of Reasons for Currently Using Contraception, by Selected Characteristics: Currently Married Women Aged 15-44 1991 Family Health Survey Selected Characteristics Pregnancies Limit Pregnancies Total No. of Cases (Unweighted) Total Residence Urban Rural Age 15-19 20-24 25-29 30-34 35-39 40-44 No. of Living Children 0 1 2 3 4 5 6+ Years of Education None 1-7 8 9-12 13+ Current Method Female Sterilization Orals Injection Rhythm/Billings Condoms IUD Other Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other 33.2 32.9 34.2 82.2 71.5 46.9 23.7 4.1 5.6 ** 81.4 53.5 34.6 18.3 9.6 10.4 26.0 32.7 25.6 46.3 39.5 0.0 56.8 55.9 54.5 50.0 52.4 55.1 33.0 33.1 37.3 30.6 32.4 66.8 67.1 65.8 17.8 28.5 53.1 76.3 95.9 94.4 ** 18.6 46.5 65.4 81.7 90.4 89.6 74.0 67.3 74.4 53.7 60.5 100.0 43.2 44.1 45.5 50.0 47.6 44.9 67.0 66.9 62.7 69.4 67.6 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (846)* (596) (250) (37) (137) (222) (213) (131) (106) (20) (84) (182) (158) (128) (109) (165) (39) (219) (321) (203) (64) (324) (285) (80) (50) (32) (38) (37) (262) (412) (70) (42) (60) *Excludes 2 cases for whom reason for using is unknown. **Less than 25 cases. Table 5-20 Belize: Mean Age and Mean Number of Children at Time of First Contraceptive Use: Ever-Users of Contraception 1991 Family Health Survey Selected Characteristics Mean No. Children Mean Age No. of Cases (Unweighted) Residence Urban Rural Years of Education None 1-7 8 9-12 13+ No. Household Amenities 0-2 3-7 8-10 Ethnic Group* Creole Mestizo Garifuna Maya/Ketchi Religion** Protestant Catholic Total 3.5 4.7 6.6 5.6 3.5 2.1 4.1 5.8 3.3 3.4 2.5 5.0 3.1 3.7 3.0 4.5 3.8 27.3 29.9 30.0 31.4 27.9 25.0 26.5 29.0 27.8 27.4 25.0 29.6 30.2 29.1 22.6 28.6 27.9 (1,104) (401) (55) (364) (545) (407) (134) (296) (796) (413) (558) (640) (128) (73) (599) (813) (1,505) *Excludes those whose ethnic group was classified as "other." **Excludes those whose religion was classified as "other." Table 5-21 Belize: Percent Distribution of Ever-Married Women Aged 15-44, by Number of Living Children at Time of First Contraceptive Use, According to Actual Age 1991 Family Health Survey No. of Children at First Use Actual Age 0 1 2 3 4+ Never Used Total No. of Cases* (Unweighted) Total 15-19 20-24 25-29 30-34 35-39 40-44 14.4 21.0 19.0 16.7 12.4 8.3 8.7 17.1 16.0 17.5 18.3 18.7 14.7 14.7 12.8 7.2 11.5 14.1 13.9 16.2 10.6 8.2 1.1 6.9 9.5 10.9 9.2 6.9 15.0 0.5 2.8 11.2 18.1 27.2 30.9 32.5 54.1 42.2 30.2 25.9 24.5 28.1 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (1,905) (127) (376) (515) (429) (249) (209) *Excludes 36 cases for whom number of children at first use is unknown. Table 5-22 Percent Distribution of Currently Married Women Aged 15-44 Currently Using Contraceptives, by Method: Mexico, Central America, Caribbean, and Panama Current Use and Method Costa Rica (1986) Panama (1984) Jamaica* (1989) Mexico* (1987) Trinidad/ Tobago (1987) El Salvador (1988) Belize (1991) Honduras (1987) Guatemala (1987) Currently Using Female Sterilization Orals IUD Condoms Rhythm/Billings Other Methods Not Currently Using Total 69.5 14.4 20.7 8.0 13.4 8.1 4.9 30.5 100.0 58.2 2.8 11.8 6.0 1.6 2.3 3.7 41.8 100.0 54.6 13.6 19.5 1.5 8.6 1.0 10.4 45.4 100.0 52.7 18.6 9.7 10.2 1.9 8.0 4.3 47.3 100.0 52.7 8.2 14.0 4.4 11.8 2.6 11.7 47.3 100.0 47.1 29.6 7.6 2.0 2.4 2.4 3.1 52.9 100.0 46.7 18.7 14.9 1.9 1.9 2.5 6.7 53.3 100.0 40.6 12.6 13.4 4.3 1.8 3.5 4.9 59.4 100.0 23.2 10.3 3.9 1.8 1.2 2.8 3.2 76.8 100.0 Number of Cases (Unweighted) (1,914) (5,222) (6,112) (5,447) (4,359) (2,276) (1,788) (6,093) (3,377) *Married women 15-49 years of age. Table 5-23 Belize: Source of Contraception, by Residence, for Current Users of Contraception: Currently Married Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Residence Source of Contraception Total Urban Rural Government Facilities BFLA Pharmacy Private Facilities Self/Partner Outside of Belize Other/Unknown Total 38.2 10.3 29.0 12.7 4.6 1.7 3.6 100.0 37.3 9.3 32.4 12.4 3.7 1.2 3.7 100.0 40.6 13.0 19.9 13.4 6.9 2.9 3.3 100.0 No. of Cases* (Unweighted) (846) (598) (248) *Excludes 2 cases for whom source of contraception is unknown. Table 5-24 Belize: Source of Contraception, by Years of Education, for Current Users of Contraception: Currently Married Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Years of Education Source of Contraception Total 0-7 8 9+ Government Facilities BFLA Pharmacy Private Facilities Self/Partner Outside of Belize Other/Unknown Total 38.2 10.3 29.0 12.7 4.6 1.7 3.6 100.0 43.0 3.8 25.6 13.3 7.0 2.2 5.1 100.0 45.7 11.9 21.3 13.3 3.6 2.1 2.1 100.0 23.8 15.0 42.0 11.4 3.3 0.7 3.9 100.0 No. of Cases* (Unweighted) (846) (258) (319) (269) *Excludes 2 cases for whom source of contraception is unknown. Table 5-25 Belize: Source of Contraception, by Ethnic Group, for Current Users of Contraception: Currently Married Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Ethnic Group Source of Contraception Total Creole Mestizo Garifuna Maya/ Ketchi Other Government Facilities BFLA Pharmacy Private Facilities Self/Partner Outside of Belize Other/Unknown Total 38.2 10.3 29.0 12.7 4.6 1.7 3.6 100.0 34.6 15.9 36.9 6.1 2.9 0.7 2.9 100.0 41.2 3.8 25.9 17.8 5.7 1.8 3.8 100.0 34.9 30.1 15.7 8.4 0.0 3.6 7.2 100.0 38.8 14.3 20.4 18.4 4.1 2.0 2.0 100.0 36.1 5.6 37.5 6.9 9.7 2.8 1.4 100.0 No. of Cases* (Unweighted) (846) (262) (411) (70) (42) (61) *Excludes 2 cases for whom source of contraception is unknown. Table 5-26 Belize: Source of Contraception for Methods Requiring Resupply or Surgical Intervention, for Current Users of Contraception: Currently Married Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Method Source of Contraception Total Female Sterilization Orals Injection IUD Condom Government Facilities BFLA Pharmacy Private Facilities Outside of Belize Other/Unknown Total 41.2 11.0 31.1 13.1 1.8 1.7 100.0 86.9 0.0 0.0 11.9 0.0 1.2 100.0 4.7 17.7 66.1 6.2 3.7 1.5 100.0 6.5 33.3 22.6 31.2 4.3 2.1 100.0 23.8 19.0 4.8 52.4 0.0 0.0 100.0 2.4 9.5 78.6 0.0 0.0 7.1 100.0 No. of Cases* (Unweighted) (780) (322) (285) (80) (38) (32) *Excludes 2 cases for whom source of contraception is unknown. Table 5-27 Belize: Percent Distribution of Reasons for Not Currently Using Contraceptives, by Residence: Currently Married Women Aged 15-44 1991 Family Health Survey Residence Reasons for Nonuse Total Urban Rural Reasons Related to Pregnancy, Fecundity, and Sexual Activity Currently Pregnant Desires Pregnancy Not Sexually Active Menopause/Subfecund Postpartum/Breastfeeding Other Reasons Had or Fears Side Effects Doesn't Like/Want Lacks Knowledge of Methods Health Reasons Lacks Money Spouse Opposes Embarrassed to Use Religious Reasons Advanced Age Other Unknown Total 58.7 20.8 13.9 8.7 8.2 7.1 41.3 9.0 7.9 7.7 1.8 1.3 1.2 1.1 0.9 0.9 4.4 4.9 100.0 64.5 21.4 15.9 9.9 11.0 6.3 35.5 6.7 8.2 4.7 2.2 1.2 1.5 0.5 0.7 0.5 5.7 3.8 100.0 52.6 20.2 11.9 7.4 5.2 7.9 47.4 11.5 7.6 11.0 1.4 1.4 0.9 1.8 1.3 1.3 3.1 6.1 100.0 No. of Cases (Unweighted) (942) (479) (463) Table 5-28 Belize: Percent Distribution of Reasons for Not Currently Using Contraceptives, by Years of Education: Currently Married Women Aged 15-44 1991 Family Health Survey Years of Education Reasons for Nonuse Total 0-7 8 9+ Reasons Related to Pregnancy, Fecundity, and Sexual Activity Currently Pregnant Desires Pregnancy Not Sexually Active Menopause/Subfecund Postpartum/Breastfeeding Other Reasons Had or Fears Side Effects Doesn't Like/Want Lacks Knowledge of Methods Health Reasons Lacks Money Spouse Opposes Embarrassed to Use Religious Reasons Advanced Age Other Unknown Total 58.7 20.8 13.9 8.7 8.2 7.1 41.3 9.0 7.9 7.7 1.8 1.3 1.2 1.1 0.9 0.9 4.4 4.9 100.0 53.1 19.9 11.9 8.2 5.9 7.2 46.9 9.6 6.8 14.1 1.8 1.9 1.4 1.4 1.8 0.4 3.9 3.9 100.0 60.8 19.0 14.0 8.3 10.5 9.0 39.2 9.7 6.5 3.7 2.5 1.0 1.0 1.0 0.3 1.0 5.5 7.0 100.0 67.3 25.6 18.2 10.3 9.5 3.7 32.7 6.6 12.4 0.8 0.8 0.4 1.2 0.8 0.4 1.7 3.7 3.7 100.0 No. of Cases (Unweighted) (942) (421) (324) (97) Table 5-29 Belize: Percent Distribution of Reasons Stopped Using Contraception, by Last Method Used: Currently Married Women Aged 15-44 Who Had Used Contraception in the Past But Are Not Currently Using 1991 Family Health Survey Last Method Used Reason Stopped Using Contraception Total Orals Injection Condoms Desires Pregnancy Had or Fears Side Effects Doesn't Like or Want to Use Method Not Effective Health or Medical Reasons Not Sexually Active Lack of Money Far Distance Source Other Unknown Total 32.9 29.4 9.2 6.4 4.2 3.9 2.6 1.7 7.2 2.2 100.0 32.5 38.0 4.7 3.5 3.1 5.0 2.3 2.7 7.0 0.8 100.0 29.7 35.9 10.9 4.7 3.1 1.64 .7 0.0 6.3 3.1 100.0 33.3 2.4 30.9 11.9 4.8 2.4 4.8 0.0 4.8 4.8 100.0 No. of Cases* (Unweighted) (367)** (203) (56) (32) *Excludes one case for whom reason stopped using is unknown. **Total includes 76 users of other methods. Table 5-30 Belize: Percent of Nonusers Who Desire to Use a Method in the Future and Knowledge of Availability, by Selected Characteristics: Currently Married Women Aged 15-44 1991 Family Health Survey Selected Characteristics Percent Who Desire to Use Contraceptives Percent of Those Who Desire to Use Who Know Where to Obtain Method Total Residence Urban Rural Age 15-19 20-24 25-29 30-34 35-44 No. of Living Children 0 1 2 3 4 5 6+ Years of Education 0-7 8 9+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other 54.4 62.2 46.7 65.3 62.0 66.2 45.6 30.2 62.0 60.5 58.0 58.6 42.2 52.9 45.0 48.2 51.8 72.1 60.4 53.7 63.4 43.0 53.5 (859)* (426) (433) (87) (215) (247) (165) (145) (104) (142) (137) (147) (98) (82) (149) (389) (291) (179) (189) (448) (54) (116) (51) 75.5 81.0 68.0 60.2 73.0 80.6 83.1 77.4 64.7 82.6 69.2 77.9 77.5 80.0 76.9 65.1 76.1 89.9 83.8 73.6 88.9 51.7 80.7 (458) (266) (192) (50) (130) (160) (76) (42) (59) (82) (77) (84) (43) (43) (70) (180) (152) (126) (117) (238) (30) (45) (28) *Excludes 38 cases for whom desire to use in the future is unknown and 45 cases who are menopausal or subfecund. Table 5-31 Belize: Percent Distribution of Nonusers Who Desire to Use a Method in the Future, by Method of Choice and Source Where Method Would be Obtained, by Residence: Currently Married Women Aged 15-44 1991 Belize Family Health Survey Residence Method of Choice Total Urban Rural Orals Female Sterilization Injection IUD Rhythm/Billings Vaginal Methods Condoms Other Unknown Total 24.5 24.2 19.1 4.2 3.3 2.8 2.8 1.2 17.9 100.0 30.9 26.6 16.2 3.4 3.4 3.7 3.4 0.3 12.2 100.0 16.0 20.9 22.9 5.3 3.3 1.6 2.0 2.5 25.4 100.0 No. of Cases (Unweighted) (458) (266) (192) Source Where Method Would be Obtained* Government Facilities BFLA Pharmacy Private Facilities Other Total 25.8 22.1 30.9 17.7 3.5 100.0 16.7 23.5 36.0 21.2 2.7 100.0 40.4 19.9 22.9 12.0 4.8 100.0 No. of Cases** (Unweighted) (351) (217) (134) *Excludes women who do not know a source of contraception. **Excludes one case for whom source is unknown. 35 6. Women in Need of Family Planning Services Of the married, fecund women who stated that they did not currently desire a pregnancy, 49 percent were using a contraceptive method at the time of the survey (Table 6-1). Oral contraceptives was the most prevalent method followed by injectables and the rhythm/Billings methods. Use of contraception varied by place of residence, with use highest in urban areas (57 percent) and lowest in rural areas (36 percent). The differential is primarily explain- ed by the use of oral contraceptives as nearly twice as many urban women were using this method as rural women. Forty percent of married, fecund women who stated that they had all of the children that they wanted were using some form of contraception (Table 6-2). The distribution of methods currently being used by these women and patterns of use according to residence were the same as for women who did not desire a pregnancy. The survey data indicate that certain segments of the population are at greater risk of an unplanned pregnancy than others. A woman was characterized at risk of an unplanned pregnancy or "in need of family planning services" if she was not currently pregnant, stated that she did not desire to become preg- nant, and she was not using a method of con- traception for reasons not related to pregnancy, subfecundity, or sexual inactivity (it was assumed that all fecund, married women were sexually active). Thus, women defined as at risk of an unplanned pregnancy are fecund sexually active women, who were not pregnant at the time of interview, did not desire to become pregnant, and were not using a method of contraception. The estimated percentage of women at risk of an unplanned pregnancy using this definition varied by the characteristics of the women, as shown in Table 6-3. Overall, 17 percent of all women aged 15-44 were found to be at risk of an unplanned pregnancy. This represents an estimated 6,130 women 15-44 years of age in Belize. The percentage of women at risk is greater among rural women (23 percent) than among urban women (14 percent) and the proportion at risk is highest among married women (including women living in consensual unions). One out of every four married wom- en (26 percent) are at risk of an unplanned pregnancy (Figure 6-1). In general, the risk of an unplanned pregnancy increases with number of living children and is inversely related to years of education with the exception of wom- en 15-19 years old. Need of services in each age group ranges from 19 to 23 percent. The proportion at risk is greatest for Maya/Ketchi women and lowest for Creole women. The urban-rural differential is greatest for Mestizo women. The percentages in Table 6-3 indicate the segments of the population in which the risk of an unplanned pregnancy is greatest. In order to derive program goals, the women defined at risk of an unplanned pregnancy, i.e., the numerators in Table 6-3, have been distributed across categories of women, as shown in Table 6-4. Slightly greater than half (54 percent) of the women at risk live in urban areas. Fully 88 percent are married or live in a consensual union, approximately evenly split between urban and rural areas. Almost half (48 per- cent) are Mestizos, 78 percent have a primary school education or less, nearly two thirds have three or more children, and 57 percent are under the age of 30, reflecting the distribu- tion of these characteristics in the population. The data indicate that the family planning program of Belize should be oriented toward lower educated married women who live in both urban and rural areas. 36 Overall, 42 percent of women at risk of an unplanned pregnancy stated that they have ever used contraception, and 52 percent expressed a desire to use contraception sometime in the future (Table 6-5). Thus, as a group, these women have some experience with the use of contraception and about half are motivated to control their fertility. Desire to use contracep- tion in the future is highest among urban women, single women, younger women, women with fewer than four children, and better educated women. Among the principal ethnic groups, interest in future use of contra- ception is highest for Garifuna and Creole women. 37 38 Table 6-1 Belize: Percent Distribution of Currently Married Fecund Women Aged 15-44 Not Desiring a Pregnancy Who Are Using Contraceptives, by Method and Residence 1991 Family Health Survey Residence Current Use and Method Total Urban Rural Currently Using Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 48.7 25.8 7.7 4.1 3.3 3.4 4.4 51.3 100.0 57.5 31.3 8.4 4.3 4.2 3.9 5.4 42.5 100.0 35.8 17.9 6.6 3.6 2.0 2.7 2.9 64.2 100.0 No. of Cases* (Unweighted) (900) (525) (375) *Excludes sterilized women and women who said they were either subfecund or menopausal. Table 6-2 Belize: Percent Distribution of Currently Married Fecund Women Aged 15-44 Wanting No More Children Who Are Currently Using Contraceptives, by Method and Residence Residence Current Use and Method Total Urban Rural Currently Using Orals Injection Rhythm/Billings Condoms IUD Other Not Currently Using Total 40.2 21.1 6.7 3.4 2.7 2.5 3.8 59.8 100.0 47.5 29.6 7.5 3.9 2.9 2.5 4.1 52.5 100.0 29.2 12.7 5.5 2.7 2.4 2.4 3.4 70.8 100.0 No. of Cases (Unweighted) (597) (355) (242) Table 6-3 Belize: Percentage of Women Aged 15-44 Who Are In Need of Family Planning Services, by Selected Characteristics and Residence 1991 Belize Family Health Survey Residence Selected Characteristics Total Urban Rural Total Marital Status* Married/In Union Sep./Div./Widowed Visiting Partner Single Age 15-19 20-24 25-29 30-34 35-39 40-44 No. of Living Children 0 1 2 3 4 5 6+ Years of Education None 1-7 8 9-12 13+ Ethnic Group* Creole Mestizo Garifuna Maya/Ketchi Other 16.9 25.7 10.5 14.5 1.9 8.0 18.7 19.1 19.1 23.3 23.2 2.0 21.8 21.1 23.2 27.9 21.5 36.8 23.0 24.4 18.1 10.7 6.9 12.6 18.7 18.0 25.4 16.8 (2,656) (1,790) (151) (117) (598) (526) (549) (593) (483) (280) (225) (694) (353) (402) (359) (265) (216) (367) (113) (714) (918) (713) (198) (894) (1,162) (228) (220) (151) 13.7 20.5 12.2 13.4 2.8 6.5 17.1 16.9 12.6 17.1 17.8 2.3 19.2 17.2 20.8 22.4 19.7 20.7 15.4 19.4 16.4 10.5 7.2 12.6 13.2 18.2 19.7 16.4 (1,724) (1,077) (125) (106) (416) (335) (344) (383) (322) (184) (156) (479) (257) (277) (237) (173) (133) (168) (49) (331) (543) (626) (175) (757) (640) (169) (50) (108) 23.2 34.0 2.5 ** 0.0 10.9 21.7 23.7 32.8 34.6 36.7 1.3 29.2 30.7 28.7 40.0 24.7 39.9 29.7 28.9 20.8 12.0 ** 12.8 25.9 17.2 27.1 17.7 3(932) (713) (26) (11) (182) (191) (205) (210) (161) (96) (69) (215) (96) (125) (122) (92) (83) (199) (64) (383) (375) (87) (23) (137) (522) (59) (170) (43) *Excludes one case for whom ethnic group is unknown. **Less than 25 cases. Table 6-4 Belize: Percent Distribution of Women Aged 15-44 Who Are In Need of Family Planning Services, by Selected Characteristics and Residence 1991 Belize Family Health Survey Residence Selected Characteristics Total Urban Rural Total Marital Status Married/In Union Sep./Div./Widowed Visiting Partner Single Age 15-19 20-24 25-29 30-34 35-39 40-44 No. of Living Children 0 1 2 3 4 5 6+ Years of Education None 1-7 8 9-12 13+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other 100.0 88.4 3.8 4.3 3.5 12.6 22.7 21.6 16.7 13.7 12.7 4.0 17.5 15.9 15.4 14.3 8.4 24.5 5.1 36.7 36.4 18.8 3.0 26.4 47.9 9.2 11.6 4.9 (491) 54.2 43.4 3.7 3.7 3.5 6.5 13.8 12.9 7.5 6.5 7.0 3.2 11.5 9.2 9.5 7.9 5.1 7.8 1.6 14.0 19.9 15.9 2.9 22.6 19.2 6.8 2.1 3.5 45.8 45.0 0.2 0.6 0.0 6.0 8.9 8.7 9.2 7.1 5.7 0.8 6.0 6.7 5.9 6.4 3.3 16.7 3.5 22.7 16.5 2.9 0.2 3.8 28.6 2.4 9.5 1.4 Table 6-5 Belize: Women Aged 15-44 Who Are In Need of Family Planning Services: Percentage Who Have Ever Used Contraception and Percentage Who Desire to Use Contraception in the Future, by Selected Characteristics 1991 Belize Family Health Survey Selected Characteristics Ever Used Contraception Desire to Use Contraception No. of Cases (Unweighted) Total Residence Urban Rural Marital Status Ever Married Single/Visiting Partner Age 15-19 20-24 25-29 30-34 35-39 40-44 No. of Living Children 0-1 2 3 4 5 6+ Years of Education 0-7 8 9+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other 41.7 51.9 29.5 41.4 44.9 38.0 32.9 43.4 43.8 50.0 46.3 34.1 33.0 45.4 51.1 45.3 44.8 33.1 43.2 55.5 48.2 37.2 39.7 31.5 ** 51.7 56.9 45.5 50.2 69.4 65.8 68.5 67.7 40.0 32.6 16.3 65.2 60.0 56.7 36.7 50.9 40.3 47.1 49.3 64.2 59.0 49.2 65.5 43.8 ** (491) (259) (232) (460) (31) (55) (115) (121) (94) (57) (49) (97) (82) (84) (73) (50) (105) (204) (180) (107) (127) (236) (42) (62) (24) **Less than 25 cases. 39 7. Use of and Potential Demand for Surgical Contraception As discussed earlier in this report, female sterilization is the most prevalent method of contraception in Belize, accounting for 40 percent of all contraceptive use. Because of the importance of female sterilization in con- trolling unwanted pregnancies in Belize, this chapter provides additional data on sterilization and the demand for this procedure. Specifical- ly, this chapter discusses the characteristics of women with tubal ligations, post-operative regret, interest in sterilization among women who want to limit their family size, reasons for lack of interest in sterilization, and reasons for failure to follow through among interested and informed women. 7.1 Profile of Sterilized Women The top panel of Table 7-1 shows that a some- what disproportionate number of sterilized women live in urban areas. Seventy-four percent of all sterilized women in Belize live in urban areas, although urban women represent only 61 percent of the total married survey population. As in most countries, surgical contraception services are more accessible in urban areas. With regard to education, steril- ized women with 8 years of education are over-represented, while those with 1 to 7 years and 9 to 12 years of schooling are under- represented. However, women from higher socioeconomic households, measured by num- ber of household amenities, appear to be over- represented, while women from the lowest socioeconomic households appear to be under- represented. According to the Ministry of Health, most of the female sterilizations performed in Belize are interval sterilizations. Fifty-five percent of the sterilized women were in their twenties when they were sterilized. The average age of sterilized women was 29.7 when they were sterilized and 35.3 at the time of the survey compared with a mean age of 29.7 years in the survey population. Seventy-one percent of the sterilized women have four or more living children compared with only 44 percent of the married survey population. When we compare mean number of living children, we see that sterilized women have had 1.3 more children on average (4.9) than all married respondents (3.6). This finding suggests that women in Belize who seek sterilization tend to be self- selected because of their relatively high fertili- ty. As shown in the bottom panel of Table 7-1, 53 percent have been sterilized since 1986, in the five years prior to the survey. 7.2 Use of Contraception Before Sterilization Overall, tubal ligation was the first method of contraception to be used by 38 percent of sterilized women (Table 7-2). For women living in urban areas, this proportion is only 31 percent, but it is 58 percent for women living in rural areas (Figure 7-1). The proba- bility that female sterilization was the first method ever used is inversely associated with educational attainment and number of house- hold amenities. Nearly two thirds of sterilized Garifuna women reported that their first and only method of contraception was female sterilization. In contrast, only 26 percent of sterilized Creole women reported female sterilization as their first method. 7.3 Satisfaction with the Decision All married women aged 15-44 who had a tubal ligation were asked if they were satisfied with having the operation. As shown in table 7-3, 93 percent expressed satisfaction with their decision to have the operation. Women who were 15-24 years of age when they were 40 sterilized reported the lowest level of satisfac- tion (85 percent) with the procedure. Satisfac- tion was 91 percent or higher for 21 of the 25 sociodemographic subgroups shown in the table. 7.4 Demand for Sterilization All fecund married women who had at least one living child were asked if they wanted any more children. Overall, 49 percent said they did not want any more children (Table 7-4). The proportion not wanting any more children increases with age and number of living chil- dren. Almost half (46 percent) of women with 2 children and more than two thirds with 4 or more children do not want any more children. Women with 8 or fewer years of formal educa- tion were more likely to state that they did not want more children compared to women of higher educational attainment. However, as noted earlier, higher educated women tend to be younger and of lower parity. All fecund women who did not want any more children were asked whether they were inter- ested in having a tubal ligation. In addition, women who reported that they wanted more children were asked if they would be interested in having a tubal ligation after they had their desired number of children. As shown in Table 7-5, about the same percentage (38 percent) of each group said they were or would be interested in sterilization, indicating that interest in sterilization in Belize will probably not wane in the near future. For both groups, a higher percentage of urban women expressed interest in sterilization than rural women. While interest in sterilization among women wanting more children was inversely associated with age and number of living children, there were no clear trends associated with these variables among women wanting no more children. Interest in sterilization among wom- en wanting more children was directly associate- ed with educational attainment, while among women wanting no more children only those with less than an 8th grade education expressed relatively strong interest. Interest also varied among the two groups with respect to ethnici- ty, with Mestizos showing the greatest interest among those not wanting more children and the Garifunas expressing the greatest interest among those wanting more children. Of the women in each group that were interest- ed in sterilization, approximately three out of four had knowledge of a source of sterilization (data not shown). Knowledge of where to obtain sterilization did not vary appreciably between urban and rural areas. Approximately 75 percent of each group cited the Ministry of Health as a source of sterilization, while the remainder cited private clinics or hospitals. All women who said that they did not want any more children, were interested in steriliza- tion, and knew a source of sterilization were asked why they had not sought surgical contra- ception. Overall, 23 percent said they feared the operation or its side effects (Table 7-6). An additional 14 percent stated that they con- sidered themselves too young for the opera- tion, 12 percent stated that they lacked infor- mation about the operation, and 11 percent stated that they lacked the money to obtain the operation. While urban women were more likely to consider themselves too young for the operation, rural woman were more likely to state that they lacked money to obtain the operation. Overall, 9 percent of the women cited health or medical reasons for never being sterilized. Nearly three times as many urban women as rural women cited this reason. Finally, women who did not want more chil- dren and said they were not interested in surgical contraception, and women who stated that they would not be interested in surgical contraception after having all of the children they want, were asked why they were not interested (Table 7-7). Overall, 50 percent of these women stated that they feared the opera- tion or its side effects as their reason, while an additional 10 percent said they just didn't like sterilization. About 7 percent stated that they 41 preferred to use other methods to regulate their fertility, while an additional 6 percent consid- ered themselves too young. Religious reasons and spousal opposition accounted for only three percent each of the reasons given. Women with 8 years or less of schooling were more likely to state that they feared the opera- tion than women with nine or more years of schooling. Preference to use other methods to regulate fertility was directly associated with educational attainment. In summary, many of the reasons for never being sterilized or for not being interested in sterilization could be addressed through a vigorous and effective educational program. The data presented in this section suggest that some women in Belize are misinformed about the safety and efficacy of tubal ligation. This finding indicates that educational programs may be needed to dispel adverse rumors about this method. 42 Table 7-1 Belize: Demographic Profile of Currently Married Women Aged 15-44 Using Female Sterilization and All Currently Married Respondents 1991 Family Health Survey Percent Distribution At: Selected Characteristics Time of Sterilization Time of Survey Currently Married Survey Population Total Residence Urban Rural Age* 15-19 20-24 25-29 30-34 35-39 40-44 Mean Age No. of Living Children 0 1 2 3 4 5 6+ Mean No. of Living Children Years of Education None 1-7 8 9-12 13+ No. Household Amenities 0-2 3-7 8-10 100.0 (324) - - 1.3 13.9 40.7 23.2 16.4 4.5 29.7 - - - - - - - - - - - - - - - - 100.0 (324) 73.6 26.4 0.2 3.0 14.6 26.2 25.7 30.4 35.3 0.2 1.7 10.1 17.3 21.5 16.8 32.3 4.9 7.2 25.2 47.7 13.6 6.4 18.0 56.3 25.7 100.0 (1,790) 61.5 38.5 7.9 19.8 24.6 20.0 14.4 13.2 29.7 8.1 13.9 17.3 16.7 13.1 10.2 20.7 3.6 5.8 32.5 36.4 19.3 6.1 30.5 47.6 21.9 *Excludes 7 cases for whom age and year of sterilization is unknown. Table 7-1 (Continued) Belize: Demographic Profile of Currently Married Women Aged 15-44 Using Female Sterilization and All Currently Married Respondents 1991 Family Health Survey Percent Distribution At: Selected Characteristics Time of Sterilization Time of Survey Currently Married Survey Population Year of Sterilization* Before 1980 1980-1981 1982-1983 1984-1985 1986-1987 1988-1989 1990-1991 (Jan.-Feb.) 16.8 8.1 7.9 14.1 15.3 22.5 15.3 - - - - - - - - - - - - - - *Excludes 7 cases for whom age and year of sterilization is unknown. Table 7-2 Belize: Percentage of Married Women Aged 15-44 With Surgical Contraception Whose First Method of Contraception Was Tubal Ligation, by Selected Characteristics 1991 Family Health Survey Selected Characteristics Percentage No. of Cases (Unweighted) Total Residence Urban Rural Age 15-29 30-34 35-39 40-44 Years of Education 0-7 8 9+ No. Household Amenities 0-2 3-7 8-10 No. of Living Children 0-2 3 4 5 6+ Ethnic Group Creole Mestizo Garifuna Other Years of Sterilization Before 1980 1980-1983 1984-1987 1988-1991 (Jan.-Feb.) 38.3 31.2 57.9 50.0 34.0 35.6 37.4 48.9 39.4 18.5 61.4 41.2 15.4 38.8 47.1 29.9 32.3 42.0 25.7 38.5 63.6 48.9 38.2 40.0 42.0 34.6 (324) (234) (90) (65) (97) (79) (83) (103) (154) (67) (60) (186) (78) (45) (58) (70) (56) (95) (86) (172) (28) (38) (46) (50) (100) (128) Table 7-3 Belize: Percentage of Sterilized Women Who Reported Satisfaction With Surgical Contraception, by Selected Characteristics: Currently Married Women Aged 15-44 Who Are Sterilized 1991 Family Health Survey Selected Characteristics Percent Satisfied No. of Cases (Unweighted) Total Residence Urban Rural Age at Time of Sterilization 15-24 25-29 30-34 35-44 Years of Education 0-7 8 9+ No. Household Amenities 0-2 3-7 8-10 No. of Living Children 0-2 3 4 5 6+ Ethnic Group Creole Mestizo Garifuna Other 93.1 92.9 93.5 85.0 93.8 96.7 95.2 92.4 93.8 92.6 87.7 92.1 99.0 91.8 87.1 96.5 94.1 93.9 97.3 91.7 90.9 91.1 (324) (234) (90) (52) (129) (76) (60) (103) (154) (67) (60) (186) (78) (45) (58) (70) (56) (95) (86) (172) (28) (38) Table 7-4 Belize: Percentage of Currently Married Fecund Women Aged 15-44 Who Want No More Children, by Selected Characteristics 1991 Family Health Survey Selected Characteristics Percentage No. of Cases (Unweighted)* Total Residence Urban Rural Age 15-19 20-24 25-29 30-34 35-39 40-44 No. of Living Children 1 2 3 4 5 6+ Years of Education None 1-7 8 9-12 13+ Ethnic Group** Creole Mestizo Garifuna Maya/Ketchi Other 49.0 51.5 45.7 15.3 37.9 42.8 58.3 69.5 83.9 14.4 37.0 46.0 65.4 69.7 78.4 53.1 49.3 51.7 45.2 40.7 53.5 48.9 44.9 45.4 43.0 (1,258) (707) (551) (92) (294) (387) (268) (142) (75) (219) (282) (247) (156) (135) (219) (72) (438) (418) (260) (70) (324) (186) (88) (132) (82) *Excludes 2 cases for whom desire to have more children is unknown. **Excludes one case for whom ethnic group is unknown. Table 7-5 Belize: Percentage of Currently Married Fecund Women Aged 15-44 Who Are Interested in Sterilization, by Current Desire to Have More Children and Selected Characteristics 1991 Family Health Survey Selected Characteristics Interest of Women Who Want No More Children Interest of Women After They Have Desired No. of Children Total Residence Urban Rural Age 15-24 25-29 30-34 35-44 No. of Living Children 1-2 3 4 5 6+ Years of Education 0-7 8 9+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other 38.4 43.6 30.6 40.7 50.0 44.2 23.6 38.0 45.2 38.7 39.4 34.5 43.2 34.7 35.5 31.4 45.4 34.7 26.1 37.5 (597) (355) (242) (123) (165) (154) (155) (133) (108) (98) (94) (164) (243) (211) (143) (171) (292) (41) (57) (36) 36.7 43.5 28.6 40.6 39.8 32.5 17.1 41.1 37.8 30.2 23.3 19.0 31.8 38.0 42.3 36.1 39.7 48.3 13.3 41.5 (661)* (352) (309) (263) (222) (114) (62) (368) (139) (58) (41) (55) (267) (207) (187) (153) (339) (47) (75) (46) *Excludes 2 cases for whom interest in sterilization is unknown and one case for whom ethnic group is unknown. NOTE: Figures in parentheses are unweighted numbers of cases. Table 7-6 Belize: Percent Distribution of Reasons Never Sterilized, by Residence: Currently Married Fecund Women Aged 15-44, Who Want No More Children, Who Are Interested in Sterilization, and Who Have Knowledge of Where to Obtain Sterilization Information and/or Services 1991 Family Health Survey Residence Reasons Never Sterilized Total Urban Rural Fears Operation/Side Effects Considers Self Too Young Lack of Information Lack of Money Health or Medical Reasons Spouse Opposes Advanced Age Far Distance to Source Prefers Using Other Methods Not Sexually Active Doesn't Like or Want to Use Religion Other Doesn't Know Total 22.7 13.9 12.5 11.1 9.3 3.7 1.4 1.4 1.4 0.9 0.5 0.5 15.3 5.6 100.0 21.9 17.8 13.7 8.2 11.6 2.7 2.0 1.4 2.0 1.4 0.0 0.0 12.3 4.8 100.0 24.3 5.7 10.0 17.1 4.3 5.7 0.0 1.4 0.0 0.0 1.4 1.4 21.4 7.1 100.0 No. of Cases (Unweighted) (189) (123) (66) Table 7-7 Belize: Percent Distribution of Reasons Never Sterilized, by Number of Living Children: Currently Married Fecund Women Aged 15-44, Who Want No More Children, Who Are Interested in Sterilization, and Who Have Knowledge of Where to Obtain Sterilization Information and/or Services 1991 Family Health Survey No. of Living Children Reasons Never Sterilized Total 1-2 3 4 5 6+ Fears Operation/Side Effects Considers Self Too Young Lack of Information Lack of Money Health or Medical Reasons Spouse Opposes Advanced Age Far Distance to Source Prefers Using Other Methods Not Sexually Active Doesn't Like or Want to Use Religion Other Doesn't Know Total 22.7 13.9 12.5 11.1 9.3 3.7 1.4 1.4 1.4 0.9 0.5 0.5 15.3 5.6 100.0 10.2 34.7 12.2 2.0 2.0 2.0 6.1 4.1 4.1 2.0 0.0 0.0 12.2 8.2 100.0 15.4 20.5 12.8 15.4 7.7 2.6 0.0 2.6 0.0 0.0 0.0 0.0 17.9 5.1 100.0 23.1 5.1 20.5 15.4 10.3 5.1 0.0 0.0 0.0 2.6 2.6 0.0 10.3 5.1 100.0 31.0 3.5 20.7 10.3 17.2 3.5 0.0 0.0 3.5 0.0 0.0 0.0 6.9 3.5 100.0 33.3 3.3 3.3 13.3 11.7 5.0 0.0 0.0 0.0 0.0 0.0 1.7 23.3 5.0 100.0 No. of Cases (Unweighted) (189) (44) (35) (35) (29) (46) Table 7-8 Belize: Percent Distribution of Reasons Not Interested in Sterilization, by Years of Education: Currently Married Fecund Women Aged 15-44 Who Said They Were Not Interested in Sterilization* 1991 Family Health Survey Years of Education Reasons Not Interested in Sterilization Total 0-7 8 9+ Fears Operation/Side Effects Doesn't Like or Want to Use Prefers Using Other Methods Considers Self Too Young Lack of Information Advanced Age Spouse Opposes Religion Health or Medical Reasons Not Sexually Active Far Distance to Source Lack of Money Other Doesn't Know Total 49.8 10.1 7.4 6.2 4.0 3.8 3.2 3.2 2.4 0.9 0.5 0.3 3.1 5.2 100.0 50.7 9.3 4.1 5.8 6.4 3.8 3.8 4.3 2.0 1.7 0.3 0.3 2.3 5.2 100.0 56.9 9.1 6.4 3.7 2.4 4.4 2.0 2.4 3.4 0.0 1.0 0.7 2.7 4.7 100.0 38.4 12.8 14.2 10.4 2.4 2.8 3.8 2.4 1.4 0.9 0.0 0.0 4.7 5.7 100.0 No. of Cases (Unweighted) (714) (287) (244) (183) *Includes women who currently want no more children and women who would not be interested in sterilization after having all of the children they want. 43 8. Use of Maternal and Child Health Services This chapter covers the use of maternal and child health (MCH) services for each pregnan- cy that resulted in a live birth within five years of interview to women aged 15-44. Various factors influencing the use of prenatal, postpar- tum, and newborn services as well as location and type of delivery (Cesarean versus vaginal) are examined. The use of MCH services is also assessed in terms of its association with contraceptive use. 8.1 Prenatal Care Ninety-five percent of women obtained prena- tal care during pregnancy for live births that occurred within five years of interview (Table 8-1). There were no significant differences in the use of prenatal care according to place of residence, education, and ethnic group (Table 8-2). Overall, the majority of women (87 percent) used government facilities as their primary source of prenatal care. An additional 13 percent used private facilities while nurse midwives and traditional birth attendants accounted for less than one percent of the prenatal care received in the past five years. Women of high educational attainment were the most likely to use private facilities for their prenatal care. Timing of the first prenatal visit is important in that the earlier this visit is made the earlier problems can be detected and managed. Of live births for which prenatal care was ob- tained, less than half received their first prena- tal check-up during the first three months of pregnancy. Almost 50 percent of the women waited until the second trimester of pregnancy for their first checkup and 4 percent did not initiate prenatal care until the last trimester. Urban women, women with 9 or more years of schooling, Creoles, Mestizos, and women whose ethnic group was classified as "other" tended to receive their first checkup earlier. For more than three fourths of live births, women who received prenatal care had 5 or more examinations during their pregnancies. Again, women who live in urban areas and women with more education were more likely to have made five or more prenatal visits than rural women and women with less education. Creoles and women whose ethnic group was classified as "other" made the most prenatal visits compared to the other ethnic groups. Women receiving tetanus injections during pregnancy protect their newborns from neona- tal tetanus. The Belize Ministry of Health recommends that women receive two doses of tetanus toxoid during their first pregnancy and one dose during each subsequent pregnancy. After this, a booster is given every five years. Overall, for 84 percent of pregnancies result- ing in a live birth there was at least one inject- tion received (Table 8-3). The proportion receiving a tetanus injection did not vary by residence, education, and ethnic group. How- ever, those who received no prenatal care were the least likely to be vaccinated against tetanus. 8.2 Location and Type of Last Delivery In general, more than three fourths of births in the last five years were delivered in either a government or private hospital (Table 8-4, Figure 8-1). This percentage is 93 percent for women living in urban areas but only 57 percent for women living in rural areas. About 90 percent of Creole and Garifuna births were delivered in a hospital compared to only 52 percent of the Maya/Ketchi. Overall, 21 percent of the children were delivered at home. Rural births (40 percent) were much more likely to occur at home than urban births (5 percent). The Maya/Ketchi, who primarily 44 live in rural areas, reported the highest pro- portion of children delivered at home (46 percent). The probability of delivery at home increases as the educational level of the mother decreases, reflecting the lower educational levels of rural women. Sixty percent of the deliveries were attended by a nurse midwife (Table 8-5). An additional 20 percent were attended by traditional birth attendants (TBA), followed by physicians (17 percent). Less than one percent of deliveries were reported to be unattended. Twice as many births to urban women and to women of high educational attainment were attended by physicians compared to other women. Rural women, the Maya/Ketchi, and Mestizos were the most likely to report that they were attend- ed by TBAs. The probability of being attend- ed by a TBA was also inversely associated with educational level. Women whose deliveries were in a hospital (76 percent of all deliveries) were asked if their deliveries were vaginal or Cesarean. Overall, 8 percent of deliveries occurring in a hospital were Cesarean (Table 8-6). The hospital rate of 8 percent compares to the rate of 32 percent reported in Brazil in 1986, which is the highest rate in Latin America (Arruda et al., 1987). As education increases, so does the proportion of deliveries that are Cesarean. In addition, the percentage of deliveries in private hospitals that were Cesarean (14 percent) was nearly twice that of deliveries attended in government hospitals (8 percent). Finally, the Cesarean rate for all births, regardless of place of deliv- ery, was 6 percent. 8.3 Postpartum Care and Newborn Checkup Less than half of live births in the past five years were followed by use of postpartum services for the mother (Table 8-7). Urban women (48 percent) were more likely than rural women (31 percent) to receive postpar- tum care. In addition, the likelihood of receiv- ing a checkup was positively associated with higher educational attainment. With respect to ethnicity, the Creoles (55 percent), Garifuna (55 percent), and those classified as "other" (50 percent) reported the greatest use of post- partum care. The United Nations recommends a newborn checkup as soon as possible after birth for tuberculosis immunization (if not given at time of birth) and a polio and DPT vaccination series beginning at six weeks of age (UNICEF, 1989). Only 58 percent of newborns were taken for a checkup (Table 8-7). In other countries in the region, this service is generally the most used among the MCH services dis- cussed in this chapter. The low use rate may be explained by the fact that rural women do not have the same access to health services as urban women. As the table shows, nearly twice as many urban newborns (74 percent) as rural newborns (40 percent) were taken for a checkup. The proportion of women using newborn checkups increases as the level of education increases, and the Creoles (79 per- cent) and the Garifunas (78 percent) reported the greatest use of newborn checkups. 8.4 Use of MCH Services When prenatal, postpartum, and newborn services are examined together, only 34 per- cent of births in the last five years were ac- companied by use of all three services (Table 8-8). An equal proportion of women used prenatal services only. More urban woman (43 percent) than rural women (25 percent) used all three MCH services. The probability of using all three services was directly associ- ated with educational attainment (Table 8-9, Figure 8-2), with 59 percent of women with nine or more years of education reporting the use of all three health services compared to only 26 percent of women with less than 8 years of schooling. The Creoles (51 percent), the Garifuna (47 percent), and those classified as "other" (46 percent) reported the greatest use of all the three services (Table 8-10). In 45 contrast, Mestizos (27 percent), and the Ma- ya/Ketchi (23 percent) reported the lowest use rate of the three services. It should be noted that of those mothers who did not use all three services, more than one third reported using the two services, prenatal and newborn, that potentially have the greatest impact on their babies' health. Finally, women who received all three MCH services were more likely to report that they were using contraception than women who received only some or none of those services. As shown in Table 8-11, twice as many wom- en who received all three services (52 percent) were using contraception at the time of the survey as women who used no maternal and child health service (26 percent). We cannot say that the use of MCH services influences the use of contraception or vice versa. How- ever, the fact that contraceptive use among nulliparous women is relatively low in Belize and increases with parity suggests that wo- men's first exposure to family planning may indeed be in the MCH setting, which can be effectively used to promote the use of contra- ception. On the other hand, we cannot dis- count that an increase in parity may have simply been the key factor in the decision to use contraception. 46 Table 8-1 Belize: Use of Prenatal Care, by Residence and Years of Education: Live Births Within 5 Years of Interview to Currently Married Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Residence Years of Education Prenatal Care Total Urban Rural 0-7 8 9+ Yes No Total No. of Cases (Unweighted) Source of Prenatal Care Government Facility Private Facility Midwife/TBA Other Months Pregnant When First Received Care < 3 Months 4-6 Months 7-9 Months Doesn't Remember No. of Prenatal Visits 1-4 5-8 9-12 13+ Doesn't Remember Total 95.5 4.5 100.0 (1,991) 86.9 12.5 0.5 0.1 42.8 49.4 4.1 3.7 17.5 54.4 18.4 3.6 6.1 100.0 95.9 4.1 100.0 (1,035) 84.7 14.9 0.3 0.0 49.1 44.2 3.7 3.0 11.7 50.8 25.6 6.1 5.8 100.0 95.1 4.9 100.0 (956) 89.3 9.7 0.7 0.3 35.6 55.5 4.5 4.4 24.1 58.6 10.1 0.7 6.5 100.0 95.5 4.5 100.0 (878) 90.3 8.7 0.7 0.3 40.0 51.5 4.9 3.5 21.8 55.9 16.2 1.6 4.6 100.0 94.5 5.5 100.0 (697) 90.1 9.5 0.4 0.0 38.1 53.9 4.3 3.7 18.0 54.8 18.0 2.4 6.8 100.0 97.3 2.7 100.0 (416) 74.3 25.5 0.2 0.0 56.4 37.8 1.9 3.9 7.8 50.8 23.5 9.7 8.2 100.0 No. of Cases (Unweighted) (1,910) (996) (914) (842) (665) (403) Table 8-2 Belize: Use of Prenatal Care, by Ethnic Group: Live Births Within 5 Years of Interview to Currently Married Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Ethnic Group Prenatal Care Total Creole Mestizo Garifuna Maya/ Ketchi Other Yes No Total 95.5 4.5 100.0 94.9 5.1 100.0 95.8 4.2 100.0 94.1 5.9 100.0 96.2 3.8 100.0 96.6 3.4 100.0 No. of Cases (Unweighted) (1,991) (436) (1,027) (158) (257) (113) Source of Prenatal Care Government Facility Private Facility Midwife/TBA Other Months Pregnant When First Received Care < 3 Months 4-6 Months 7-9 Months Doesn't Remember No. of Prenatal Visits 1-4 5-8 9-12 13+ Doesn't Remember Total 86.9 12.5 0.5 0.1 42.8 49.4 4.1 3.7 17.5 54.4 18.4 3.6 6.1 100.0 87.8 12.2 0.0 0.0 45.4 47.3 2.7 4.6 11.0 52.5 18.3 9.3 8.9 100.0 84.6 14.9 0.3 0.2 44.0 47.7 4.7 3.5 19.5 54.7 18.9 1.9 5.0 100.0 95.5 4.0 0.6 0.0 32.4 56.8 9.1 1.7 21.6 52.3 15.3 2.3 8.5 100.0 92.5 6.4 0.7 0.4 39.5 54.5 1.4 4.6 18.5 57.7 16.4 2.1 5.3 100.0 78.3 18.3 3.5 0.0 44.3 51.3 2.6 1.7 16.5 54.8 23.5 1.7 3.5 100.0 No. of Cases (Unweighted) (1,910) (338) (1,040) (345) (62) (125) Table 8-3 Belize: Percent of Mothers Vaccinated Against Tetanus During Recent Pregnancies, by Selected Characteristics: Live Births Within 5 Years of Interview to Currently Married Women Aged 15-44 1991 Family Health Survey Selected Characteristics Percent Vaccinated No. of Cases (Unweighted) Total Residence Urban Rural Years of Education 0-7 8 9+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other Source of Prenatal Care Government Facility Private Facility No Prenatal Care Other 83.8 83.7 83.9 84.7 82.1 84.7 84.5 84.3 81.3 82.5 83.2 85.8 79.1 60.8 ** (1,989) (1,035) (954) (876) (697) (416) (436) (1,025) (158) (257) (113) (1,647) (247) (81) (14) **Less than 25 cases. Table 8-4 Belize: Percent Distribution of Births in the Last 5 Years, by Place of Birth and Selected Characteristics 1991 Family Health Survey Place of Birth Selected Characteristics Govt. Hospital Private Hospital Own Home Other Total No. of Births (Unweighted) Total Residence Urban Rural Respondent's Education (years) 0-7 8 9+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other 70.0 86.6 51.1 62.1 70.3 86.1 88.0 64.3 88.8 46.9 76.5 6.0 6.3 5.6 5.7 4.5 9.0 3.9 7.7 1.1 4.8 7.6 21.5 5.4 39.7 29.5 21.7 4.0 5.3 24.9 9.6 45.9 15.1 2.6 1.7 3.6 2.7 3.5 0.8 2.8 3.1 0.5 2.4 0.8 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (1,989) (1,035) (954) (876) (697) (416) (436) (1,025) (158) (257) (113) Table 8-5 Belize: Percent Distribution of Births in the Last 5 Years, by Type of Assistance Received During Delivery and Selected Characteristics 1991 Family Health Survey Type of Assistance Selected Characteristics Nurse/M idwife TBA Doctor None Other Total No. of Births (Unweighted) Total Residence Urban Rural Years of Education 0-7 8 9+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other 60.1 70.6 48.2 55.9 61.1 67.4 76.6 54.4 73.3 44.9 63.9 20.4 7.2 35.3 26.9 21.4 4.8 7.3 25.7 10.2 31.5 12.6 16.8 22.0 10.9 12.8 15.4 27.7 16.1 18.9 15.0 8.6 22.7 0.6 0.0 1.3 1.0 0.5 0.0 0.0 0.1 0.0 4.1 0.8 2.1 0.1 4.3 3.4 1.6 0.0 0.0 1.0 1.6 11.0 0.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (1,989) (1,035) (954) (876) (697) (416) (436) (1,025) (158) (257) (113) Table 8-6 Belize: Percent of Hospital Births in the Last 5 Years That Were Cesarean, by Selected Characteristics 1991 Family Health Survey Selected Characteristics Percent Cesarean No. of Births (Unweighted) Total Residence Urban Rural Years of Education 0-7 8 9+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other No. of Living Children 0-1 2 3 4 5 6+ Location of Delivery Government Hospital Private Facility 8.4 8.8 7.8 6.2 8.8 11.3 4.5 10.6 8.9 6.0 11.0 14.5 7.4 10.0 9.5 4.8 5.2 7.9 14.0 (1,490) (956) (534) (587) (508) (395) (397) (730) (140) (127) (96) (172) (298) (326) (215) (199) (280) (1,366) (124) Table 8-7 Belize: Percentage of Pregnancies to Currently Married Women Age 15-44 Who Received Postpartum Care and Percentage of Children Born Within 5 Years of Interview Who Received a Newborn Checkup, by Selected Characteristics 1991 Family Health Survey Selected Characteristics Postpartum Care* Newborn Checkup** Total Residence Urban Rural Respondent's Education (years) 0-7 8 9+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other 40.3 48.3 31.2 33.2 35.5 63.5 54.7 34.6 54.5 25.3 49.6 (1,988) (1,035) (953) (875) (697) (416) (436) (1,024) (158) (257) (113) 58.0 73.9 39.9 46.8 55.9 85.2 79.4 49.5 78.1 38.5 67.2 (1,982) (1,031) (951) (874) (695) (413) (432) (1,023) (158) (256) (113) *Excludes three cases for whom use of postpartum care is unknown. **Excludes nine cases for whom use of newborn checkup is unknown. Note: Figures in parentheses are unweighted numbers of cases. Table 8-8 Belize: Use of Maternal and Child Health Services, by Type of Services Used and Residence: Live Births Within 5 Years of Interview to Currently Married Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Residence Maternal and Child Health Services Total Urban Rural None Prenatal Only Postpartum Only Newborn Only Prenatal/Postpartum Prenatal/Newborn Postpartum/Newborn All Three Services Total 2.4 34.7 0.2 1.1 4.8 21.6 0.9 34.4 100.0 2.0 19.9 0.0 1.2 4.2 28.7 1.0 43.1 100.0 2.8 51.5 0.4 0.9 5.5 13.5 0.7 24.5 100.0 No. of Cases (Unweighted) (1,980) (1,030) (950) Table 8-9 Belize: Use of Maternal and Child Health Services, by Type of Services Used and Years of Education: Live Births Within 5 Years of Interview to Currently Married Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Years of Education MCH Services Total 0-7 8 9+ None Prenatal Only Postpartum Only Newborn Only Prenatal/Postpartum Prenatal/Newborn Postpartum/Newborn All Three Services Total 2.4 34.7 0.2 1.1 4.8 21.6 0.9 34.4 100.0 2.7 44.1 0.4 0.9 6.0 19.1 0.5 26.3 100.0 3.2 36.4 0.0 1.6 4.5 23.2 0.6 30.4 100.0 0.2 11.7 0.0 0.4 3.0 24.1 2.1 58.5 100.0 No. of Cases (Unweighted) (1,980) (874) (694) (412) Table 8-10 Belize: Use of Maternal and Child Health Services, by Type of Services Used and Ethnic Group: Live Births Within 5 Years of Interview to Currently Married Women Aged 15-44 1991 Family Health Survey (Percent Distribution) Ethnic Group MCH Services Total Creole Mestizo Garifuna Maya/ Ketchi Other None Prenatal Only Postpartum Only Newborn Only Prenatal/Postpartum Prenatal/Newborn Postpartum/Newborn All Three Services Total No. of Cases (Unweighted) 2.4 34.7 0.2 1.1 4.8 21.6 0.9 34.4 100.0 (1,980) 2.4 15.7 0.0 1.4 2.6 25.7 1.4 50.9 100.0 (431) 2.2 41.3 0.3 1.4 6.6 20.5 0.3 27.3 100.0 (1,023) 2.7 15.0 0.0 0.0 4.3 28.0 3.2 46.8 100.0 (157) 3.1 56.4 0.0 0.3 2.1 14.8 0.3 23.0 100.0 (256) 1.7 26.9 0.0 0.0 4.2 21.9 1.7 43.7 100.0 (113) Table 8-11 Belize: Percentage of Currently Married Women Aged 15-44 Who Have Had Live Births Within 5 Years of Interview and Who Are Currently Using Contraception, by Use of Maternal and Child Health Services 1991 Family Health Survey (Percent Distribution) MCH Services Percent Currently Using Contraception No. of Cases (Unweighted) None Prenatal Only Postpartum Only Newborn Only Prenatal/Postpartum Prenatal/Newborn Postpartum/Newborn All Three Services 25.9 34.8 * * 50.9 42.4 * 52.4 (40) (688) (2) (19) (96) (428) (20) (687) **Less than 25 cases. 47 9. Breastfeeding and Weaning Practices Breastfeeding is recognized around the world as an important determinant of child survival. Breastmilk is the most complete food an infant can receive, contains all the nutrients an infant needs for the first few months of life, and is generally free of contamination (McCann et al, 1984). Also, the transmission of maternal antibodies found in breastmilk contributes to the child's immunologic defense mechanism. Furthermore, part of the health benefit of lactation derives from its contraceptive effect; frequent suckling delays the return of ovulation and thus reduces the risks attendant to short birth intervals (VanLandingham et al., 1991). According to the literature, breastfeeding offers protection to children up to one year of age, but not necessarily beyond, and that protection is greatest in the first three months of life (Feachem and Koblinsky, 1984). For the first few months, exclusive breastfeeding is more protective than partial breastfeeding which, in turn, is more protective than no breastfeeding as breastfeeding decreases expo- sure to contaminated foods and liquids. In short, an infant's chances of survival are increased if he/she is breastfed and is breastfed for as long as possible. If an infant is exclu- sively breastfed for some period of time, his/her chances of survival are still even great- er. This chapter addresses the initiation and dura- tion of breastfeeding and supplementary feed- ing patterns and concentrates on children who were born within the 24 months prior to the interview date. Twenty-nine children who died in the 24 month interim have been excluded from the analysis. 9.1 Initiation of Breastfeeding Overall, 90 percent of surviving children born within 24 months of interview were reported by their mothers to have been breastfed (Table 9-1). A higher proportion of rural children (95 percent) were reported to have been breast- fed than urban children (86 percent). As can be seen in Figure 9-1, the percent currently breastfed among children in different age groups is also consistently higher in rural than in urban areas. The likelihood of being breast- fed was inversely associated with the number of amenities found in the household at the time of the interview. However, an inverse associa- tion of breastfeeding with educational attain- ment did not emerge from the data, as expect- ed. With respect to ethnicity, the Maya/Ketchi were more likely to report breastfeeding their children than any of the other ethnic groups. The percentage of children ever breastfed did not vary appreciably by type of delivery. However, women who gave birth in a private facility were the least likely to breastfeed. Early initiation of breastfeeding is beneficial for the health of both the mother and the child. If the mother places the baby to the breast immediately after birth, the effect of suckling causes a release of oxytocin and uterine con- tractions that accelerate the delivery of the afterbirth. Early suckling also means the ingestion of colostrum, which helps guard the newborn against several types of bacteria and other harmful organisms (McCann et al., 1984). Table 9-2 provides information about when the baby is first placed at the mother's breast. Forty-six percent of the women reported that they initiated breastfeeding immediately after giving birth while an additional 33 percent initiated breastfeeding from one to 24 hours after delivery. Nineteen percent of the women delayed breastfeeding until the day following birth or later. The data suggest that rural and less educated mothers, the same groups of mothers who are the most likely to breastfeed 48 their children, tend to delay somewhat the initiation of breastfeeding. Women who deliv- er in private hospitals also tend to delay breast- feeding. Interestingly, women whose last child was delivered by Cesarean section tend to either initiate breastfeeding immediately fol- lowing birth or to delay breastfeeding for a day or so. Given that delivery by Cesarean section constitutes major abdominal surgery, one would expect a higher proportion of mothers delaying breastfeeding than was reported. 9.2 Mean Duration and Frequency of Breastfeeding As discussed in Chapter 3, the overall mean duration of breastfeeding in Belize was approx- imately 12 months (Table 3-10) among chil- dren ever breastfed. A comparison of the results of the 1991 Belize Survey with recent survey results from neighboring countries shows that Belize has the lowest reported mean duration of breastfeeding among its neighbors. In 1987, mean duration of breastfeeding in Guatemala was 20 months while in 1987 and 1988 it was 17 months in both Honduras and El Salvador, respectively (Ministerio de Salud Publica y Asistencia Social de Guatemala et al., 1987; Honduran Ministry of Health et al., 1989; and Monteith et al., 1991). As Table 3- 10 showed, factors such as urban residence, educational attainment, socioeconomic status (as measured by number of household ameni- ties), and employment may have a negative impact on breastfeeding duration in Belize. Table 9-3 shows the mean number of times children who were breastfeeding at the time of the survey were breastfed during the previous 24 hours. The major finding of this data is that the number of feeds doesn't vary apprecia- bly by age or from night to day. Thus, a child 16 months of age is breastfed just about as many times as a child who is 10 months youn- ger. The number of feedings at night is not much lower than that during the day, even for older children. 9.3 Reasons for Never Breastfeeding and for Stopping Breastfeeding Table 9-4 shows reasons for not breastfeeding children still alive at the time of the survey among children 24 months of age or less who were never breastfed. The reasons fall into two main categories: the infant's refusal to suckle (44 percent), and the mother's inability to nurse the infant, that is, insufficient milk (18 percent), nipple or breast problems (18 percent), and mother's illness (11 percent). Less than one percent of the children were not breastfed because the mother was working. Table 9-5 shows the reasons for stopping breastfeeding among ever-breastfed children still alive at the time of the interview. Twe- nty-nine percent of the mothers stopped breast- feeding because the child refused to continue breastfeeding. Another 16 percent stopped because they felt that the child had reached weaning age while 14 percent and 8 percent reported insufficient milk and breast problems, respectively. It should be noted that almost 6 percent of the women reported that they stopped breastfeeding because they became pregnant. This occurred most often after 8 months of breastfeeding. 9.4 Supplementation and Weaning Practices When foods and liquids other than breastmilk are introduced into an infant's diet and what foods are introduced can be crucial to the child's nutritional intake, growth and develop- ment, incidence of diarrhea and other infec- tions, and the mother's milk supply and dura- tion of postpartum amenorrhea. Exclusive breastfeeding is recommended for four to six months, with supplemented breastfeeding recommended for as long as feasible (World Health Organization, 1981). About 24 percent of infants less than one year of age were exclusively breastfed for the first three months (Table 9-6). Exclusive breast- feeding was less common in urban areas, 49 among the Creoles, with first born children, by more educated women, and by younger moth- ers. Particularly striking was the difference by residence: exclusive breastfeeding in the first three months was nearly five times more common in rural areas than urban areas. Nearly 41 percent of the infants were "pre- dominantly" breastfed during the first three months of life, that is, they were either exclu- sively breastfed or were given other liquids (plain water, sugar water, juice, or herbal teas) in addition to breastmilk. The remaining 59 percent of the infants were introduced to milk (formula) other than breastmilk and/or to solid food during the first three months of life. By the time infants are 6 to 9 months of age, nearly 50 percent receive both breastmilk and complementary foods (such as milk and/or solids). Interestingly, a higher proportion of rural women, who during the first three months of their infants' lives were the most likely to exclusively breastfeed, appropriately begin giving complementary foods to their children aged 6 to 9 months of age than urban women. The feeding practices of children less than 36 months of age during the 24 hours prior to interview is summarized in Table 9-7. At less than a month of age, 89 percent of infants are breastfeeding but less than half of the infants are exclusively breastfeeding. The percentage of infants that are exclusively breastfeeding decreases from 41 percent for infants under one month of age to less than 10 percent of infants aged 3-4 months. By the time infants are 5-6 months of age, only 6 percent are exclusively breastfeeding and nearly 38 percent receive no breastmilk. 50 Table 9-1 Belize: Percentage of Living Children 24 Months of Age or Less Who Were Ever Breastfed, by Selected Characteristics of Their Mothers 1991 Family Health Survey Selected Characteristics Percent Breastfed No. of Cases (Unweighted) Total Residence Urban Rural Years of Education 0-7 8 9+ No. of Household Amenities 0-2 3-7 8-10 Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other Place of Birth1 Government Facility Private Facility At Home Type of Delivery2 Vaginal Cesarean 90.0 85.8 95.5 92.2 86.6 91.1 93.5 88.1 86.3 89.9 89.3 92.0 95.1 81.7 90.0 87.3 93.1 90.7 87.0 (980) (526) (454) (416) (337) (227) (417) (459) (104) (250) (466) (87) (122) (55) (692) (64) (197) (894) (70) 1Excludes 27 cases where place of delivery was classified as "other". 2Excludes 13 cases who last delivery was assisted with forceps and 3 cases whose type of last delivery is unknown. Table 9-2 Belize: Timing of Initiation of Breastfeeding After Birth, Ever Breastfed Children 24 months of Age or Less (Last Births Only) 1991 Family Health Survey (Percent of Distribution) Timing of Breastfeeding Selected Characteristics Immediately After Birth Hours After Birth1 Days After Birth2 Un- known Total No. of Cases (Unweighted) Total Residence Urban Rural Years of Education 0-7 8 9+ Ethnic Group Creole Mestizo Garifuna Maya/Ketchi Other Place of Birth3 Govt. Facility Priv. Facility At Home Type of Delivery4 Vaginal Cesarean 46.1 49.0 42.7 43.7 48.3 47.3 52.8 41.3 42.5 49.2 50.0 47.7 32.1 42.9 46.2 49.4 33.2 33.6 32.8 34.6 31.7 33.1 29.7 36.0 34.0 30.8 33.3 35.2 26.8 29.1 35.2 12.3 19.4 16.5 22.9 20.5 18.2 19.2 16.4 22.2 17.0 20.0 14.3 15.7 41.1 27.4 17.3 38.3 1.2 0.9 1.6 1.3 1.9 0.4 1.0 0.5 6.4 0.0 2.4 1.4 0.0 0.6 1.4 0.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (793) (408) (385) (338) (262) (193) (204) (373) (73) (105) (38) (563) (51) (161) (729) (53) 1Ranges from one hour to 24 hours. Eighty-four percent of the respondents in this category initiated breastfeeding within 5 hours after delivery. 2Ranges from one day to 15 days. Eighty-nine percent of the respondents in this category initiated breastfeeding within 3 days after delivery. 3Excludes 18 cases whose place of delivery was classified as "other". 4Excludes 11 cases whose last delivery was assisted with forceps. Table 9-3 Belize: Mean Number of Times Breastfed During the Previous Night* and During the Daylight Hours of the Previous Day, by Age of Child: Children Aged 24 Months or Less Who are Currently Being Breastfed 1991 Family Health Survey Mean No. of Times Breastfed Age of Child (in Months) Previous Day Previous Night No. of Cases (Unweighted) 0-2 3-6 7-10 11-14 15-18 19-24 5.0 5.2 5.1 4.9 4.2 4.4 4.2 4.0 3.8 3.7 3.5 3.6 (80) (101) (85) (65) (51) (38) *6 p.m. to 6 a.m. Note: Excludes women who did not breastfeed their children and those who did not recall the number of times they breastfed. Table 9-4 Belize: Reason Did Not Breastfeed: Children 24 Months of Age or Less Who Were Never Breastfed 1991 Family Health Survey (Percent Distribution) Reason Did Not Breastfeed Percent Child Refused No Milk Nipple/Breast Problem Mother Ill/Weak Child Ill Working Other Total 44.3 18.3 18.3 11.3 2.6 0.9 4.3 100.0 No. of Cases (Unweighted) (92) Table 9-5 Belize: Reason Stopped Breastfeeding: Living Children 24 Months of Age or Less Who Were Ever Breastfed But No Longer Are Breastfeeding 1991 Family Health Survey (Percent Distribution) Months Breastfed Before Stopping Reason Stopped Breastfeeding Total 0-2 3-4 5-6 7-8 9-10 11+ Child Refused Weaning Age No Milk Nipple/Breast Problem Working Mother Ill/Weak Became Pregnant Child Ill/Weak Other Total 28.6 16.5 13.8 8.5 8.2 6.8 5.8 1.0 10.9 100.0 32.6 3.2 13.7 19.0 10.5 10.5 1.1 3.2 6.3 100.0 32.0 4.1 19.7 12.3 10.7 3.3 3.3 0.8 13.9 100.0 30.7 27.4 17.7 1.6 6.5 3.2 9.7 0.0 3.2 100.0 27.8 19.4 8.3 0.0 8.3 19.4 2.8 0.0 13.9 100.0 29.6 14.8 7.4 0.0 3.7 3.7 11.1 0.0 29.6 100.0 15.9 46.4 4.4 1.5 4.4 5.8 13.0 0.0 8.7 100.0 No. of Cases (Unweighted) (338) (71) (100) (50) (28) (26) (63) Table 9-6 Belize: Percentage of Living Children Within Specified Age Groups, by Types of Supplemental Feeding and Selected Characteristics 1991 Family Health Survey Selected Characteristics Exclusive Breastfeeding (0-3 Months) Predominant1 Breastfeeding (0-3 Months) Complementary2 Foods and Breastfed (6-9 Months) Ever Breastfed (0-11 Months) Total Residence Urban Rural Ethnicity Creole Mestizo Other Language Spanish Creole Other Religion Protestant Catholic Birth Order 1 2-4 5+ Mother's Age <20 20-29 30+ Mother's Education <8 years 8 years 9+ years 23.7 10.4 47.8 16.1 22.2 35.3 21.8 19.8 40.0 25.7 21.9 17.0 25.7 26.1 21.4 22.5 29.3 34.3 20.0 15.8 (150) (90) (60) (40) (165) (45) (63) (62) (25) 40.7 32.0 56.5 41.9 35.8 47.0 28.2 45.3 60.0 45.7 37.7 38.3 42.6 39.1 35.7 41.4 43.9 46.3 31.4 45.6 (150) (90) (60) (40) (65) (45) (63) (62) (25) (52) (88) (25) (82) (43) (26) (88) (36) (59) (50) (41) 49.2 39.8 59.6 44.4 49.4 55.6 47.6 48.1 * 38.1 61.3 46.5 52.2 46.2 42.4 47.8 60.0 43.2 58.7 42.1 (147) (73) (74) (42) (66) (39) (67) (57) (23) (73) (65) (28) (73) (46) (21) (92) (34) (58) (63) (26) 91.5 87.6 97.0 88.1 93.4 92.5 94.9 87.6 91.6 91.5 91.2 90.1 91.9 91.9 89.6 93.0 89.0 92.0 92.2 89.9 (447) (246) (201) (118) (206) (123) (213) (165) (69) (180) (236) (80) (229) (138) (69) (273) (105) (188) (154) (105) 1Breastfed and (plain water, sugarwater, juice, or herbal teas) or exclusive breastfeeding. 2Breastfed and (milks or solids). Table 9-7 Belize: Feeding Practices of Living Children Less Than 36 Months of Age During the 24 Hours Prior to Interview, by Age of Child 1991 Family Health Survey Age of Child (Months) Not Breastfed Breastmilk Exclusively Breastmilk and Water Only Breastmilk and Other Liquids1 Breastmilk and Other Milk2 Breastmilk and Solids Total Number of Children 0 1-2 3-4 5-6 7-8 9-11 12-17 18-23 24-35 11.1 14.6 44.4 37.7 35.3 38.5 64.2 77.7 95.1 40.7 26.4 9.6 5.7 3.5 2.5 1.2 0.8 0.4 7.4 10.0 6.1 1.9 5.9 1.6 2.1 0.0 0.0 11.1 9.1 2.6 2.8 2.4 4.1 0.9 0.4 0.2 29.6 38.2 22.6 12.3 4.7 5.7 1.2 0.8 0.4 0.0 1.8 14.8 39.6 48.2 47.5 30.5 20.2 3.9 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (20) (83) (92) (83) (68) (101) (225) (218) (413) 1Other Liquids include Sugar water, Juice, Herbal Teas and Other Liquids (may or may not have received plain water). 2Other Milk includes fresh milk, tinned or powdered milk and formula (may or may not have received other liquids). 51 10. Immunization Levels As part of the Family Health Survey, the immunization status of children less than 5 years of age was evaluated. Data were record- ed for only those children born to the women interviewed, although other children less than 5 years of age might have been living in the household. This step was taken as a measure to increase the accuracy and reliability of the immunization data. Questions were asked on the number of doses of vaccine received against tuberculosis (BCG), poliomyelitis, diphtheria-tetanus-pertussis (DPT), and measles for each child. In addition, mothers were asked if each child had a vaccination certifi- cate. If a certificate was shown to the inter- viewer, she copied the number of doses and dates of administration of each vaccine. When the mother reported there was no certificate or could not find it, the interviewer recorded the number of doses of each vaccine and the date of administration the mother reported that a particular child had received, if any. A master copy of the vaccination certificate is main- tained at the health center and a duplicate copy is given to the mother as a record of next appointment. Only two thirds of the mothers were able to provide vaccination certificates for their chil- dren. While 77 percent of rural mothers could provide certificates for their children, only 60 percent of urban mothers could. Similarly, Mestizos (73 percent) were the most likely to have their children's certificates available for the interviewer to review while mothers whose ethnic group was classified as "other" (55 percent) were the least likely to have their children's certificate available. Availability did not vary significantly by educational level. The World Health Organization (WHO) recom- mends that primary immunizations should be completed before the first birthday (WHO, 1986). The number of doses recommended by WHO for primary immunization are: three doses each of polio and DPT vaccines and one dose each of BCG and measles vaccine. According to the Belize Ministry of Health, the regimen of vaccination for polio and DPT is at 2-3 months, 4-5 months, and 6-7 months of age (Belize Ministry of Health et al., 1990). The regimen for BCG is at the time of birth and at 9 months of age for measles. If the measles vaccine is given before the first birth- day, a second dose is recommended when the child reaches 15 months of age. Since complete polio and DPT immunization should theoretically not occur until a child is at least 6 months of age, children under the age of 6 months are excluded from the analysis of coverage with these vaccines. Similarly, children under the age of 9 months are exclud- ed when the coverage of measles vaccination is examined. Since BCG can be given at birth all children are included for these analyses. Table 10-1 shows the percentage of children less than five years of age with complete immunizations, by vaccine and residence. Over 80 percent have had complete BCG, polio, DPT, and measles vaccinations. Levels of coverage do not vary significantly according to residence. The relatively high level of complete immunization in rural areas is most likely due to the regularly scheduled visits (every six weeks) of mobile health clinics to these areas. As expected, levels of coverage are similar for polio and DPT as these vaccines are generally administered simultaneously. Levels of complete immunization are highest for BCG, which may be due to the one-dose regimen required for this vaccine and to the fact that 76 percent of deliveries are attended in a hospital. Levels of complete immunization are 8 percent to 10 percent higher when only children with 52 vaccination certificates are considered (Table 10-2). For children with certificates, complete immunization levels range from 89 percent (DPT) to 97 percent (BCG). For children without certificates, from 63 percent (polio, DPT, and measles) to 71 percent (BCG) were reported to have had a complete series of vaccines (Table 10-3). Although there is no difference seen by residence for those children with certificates, reported vaccination levels for children without certificates is higher in certain areas. UNICEF considers an 80 percent coverage level as a minimum indication of having achieved universal immunization or the level required to halt the transmission of immuniz- able diseases (UNICEF, 1988). According to the survey data, overall vaccination coverage in Belize for children 9 to 59 months of age against all of the vaccine preventable diseases is 75 percent, based on information recorded on vaccination certificates and/or reported by mothers who did not show certificates for their children. (This figure increases to 84 percent for children whose immunization status was verified by their vaccination certificates). Only 47 percent of children are completely immu- nized before their first birthday. These find- ings indicate that, although Belize is close to achieving levels of immunization that are required to control the transmission of disease, children are immunized later than recommend- ed. BCG vaccine is intended to be given at birth but is often administered during the first year of life. As Table 10-4 and Figure 10-1 show, three fourths of the children were immunized before their first birthday. By the time chil- dren are one year of age or older more than 90 percent are vaccinated. Urban mothers, moth- ers with 9 or more years of schooling, and Creole mothers were the most likely to have their children vaccinated before their first birthday. The Maya/Ketchi stand out since only 79 percent of their children have received complete BCG immunization. With one excep- tion, Maya/Ketchi levels of complete BCG immunization do not reach 90 percent for any age category. Tables 10-5 and 10-6 show the percentage of children with complete polio and DPT vaccina- tions. Only 55 percent of children are com- pletely vaccinated with these vaccines before their first birthday. Children of mothers with nine or more years of education were the most likely to have been vaccinated before their first birthday. With respect to ethnic group, about the same proportion (79 percent) of Creole, Garifuna, and Maya/Ketchi have complete polio and DPT immunization. The Mestizos, however, stand out in that they reported the highest levels of primary immunization for these vaccines (about 86 percent). Measles is the most contagious of the four preventable diseases discussed in this chapter. WHO recommends that measles vaccination be administered during the ninth month of life. As Table 10-7 shows, only 53 percent of children are vaccinated before their first birth- day. However, by the time children are one year of age or older, over 80 percent have received their measles vaccination. As was the case with polio and DPT vaccination, Mestizos reported the highest percentage of children completely vaccinated against measles (85 percent). 53 54 Table 10-1 Belize: Percentage of Children Less Than 5 Years of Age With Reported Complete BCG, Polio, DPT, and Measles Immunization, by Residence 1991 Family Health Survey Residence Immunization Total Urban Rural BCG Polio* DPT* Measles** 89.9 82.1 81.4 82.0 (2,176) (1,944) (1,944) (1,831) 89.8 82.2 80.7 81.3 (1,217) (1,081) (1,081) (1,027) 87.7 82.1 82.4 83.0 (959) (863) (863) (804) *Excludes children 0 to 5 months of age. **Excludes children 0 to 8 months of age. NOTE: Figures in parentheses are unweighted numbers of cases. Table 10-2 Belize: Percentage of Children Less Than 5 Years of Age With Reported Complete BCG, Polio, DPT, and Measles Immunization Confirmed by Vaccination Certificate, by Residence 1991 Family Health Survey Residence Immunization Total Urban Rural BCG Polio* DPT* Measles** 96.7 90.0 89.1 90.1 (1,521) (1,383) (1,383) (1,288) 97.8 90.7 88.6 90.6 (773) (692) (692) (647) 95.0 89.2 89.6 89.5 (748) (691) (691) (641) *Excludes children 0 to 5 months of age. **Excludes children 0 to 8 months of age. NOTE: Figures in parentheses are unweighted numbers of cases. Table 10-3 Belize: Percentage of Children Less Than 5 Years of Age Without Vaccination Certificates With Reported Complete BCG, Polio, DPT, and Measles Immunization, by Residence 1991 Family Health Survey Residence Immunization Total Urban Rural BCG Polio* DPT* Measles** 71.1 63.5 62.8 63.3 (655) (561) (561) (543) 76.8 67.5 66.7 65.6 (444) (389) (384) (380) 56.4 52.9 52.4 57.1 (211) (172) (172) (163) *Excludes children 0 to 5 months of age. **Excludes children 0 to 8 months of age. NOTE: Figures in parentheses are unweighted numbers of cases. Table 10-4 Belize: Percentage of Children Less Than 5 Years of Age With Reported Complete BCG Immunization, by Selected Characteristics and Age of Child 1991 Family Health Survey Age of Child (in years) Selected Characteristics Total <1 1 2 3 4 Total Residence Urban Rural Years of Maternal Education 0-7 8 9+ Ethnic Group* Creole Mestizo Garifuna Maya/Ketchi Other 89.9 89.8 87.7 85.6 90.0 92.9 92.7 89.1 88.5 78.8 89.8 (2,176) (1,217) (959) (908) (758) (510) (570) (1,032) (198) (259) (116) 75.8 79.0 71.4 65.8 77.4 89.0 87.4 70.5 80.0 58.8 ** (445) (244) (201) (186) (156) (103) (117) (205) (39) (60) (24) 93.8 94.5 92.9 93.3 94.4 93.7 93.6 97.0 93.0 82.5 91.2 (485) (260) (225) (208) (163) (114) (122) (233) (48) (53) (29) 91.2 93.6 87.8 87.9 93.5 93.7 94.7 92.4 95.7 79.3 ** (412) (227) (185) (173) (140) (99) (103) (212) (39) (42) (16) 93.5 92.9 94.6 92.5 93.9 94.9 97.3 92.3 82.9 92.3 100.0 (422) (258) (164) (181) (140) (101) (119) (186) (34) (57) (26) 91.2 89.4 93.7 88.8 92.0 93.7 91.7 92.5 90.9 83.0 ** (412) (228) (184) (160) (159) (93) (109)

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