1993 Contraceptive Prevalence Survey Jamaica Volume V Summary of Results by Health Region

Publication date: 1994

1993 Contraceptive Prevalence Survey JAMAICA CONTRACEPTIVE PREVALENCE SURVEY JAMAICA 1993 VOLUME V SUMMARY OF RESULTS BY HEALTH REGION Carmen P. McFarlane, M.Sc. (Econ.) Jay S. Friedman, M.A. Leo Morris, Ph.D., M.P.H. Susanna C. Binzen, M.P.H. NATIONAL FAMILY PLANNING BOARD December, 1994 PRINTED BY: U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention Atlanta, Georgia 30333 PREFACE The 1993 Jamaica Contraceptive Prevalence Survey (CPS) is the fifth in a series of periodic enquiries conducted by the National Family Planning Board (NFPB). The Survey seeks to update measures of fertility and contraceptive use among women aged 15-44 years and will for the first time include a special module for young adults (male and female) aged 15-24 years as well as males aged 15-54 years. The scope of the survey, as in earlier studies, is designed to gather information on a broad range of areas including knowledge, attitudes, and practices in contraception, and perceptions on the roles of men and women including views on sexuality, child bearing, child rearing, and health care. . This CPS, coming as it does in the last decade of the century, is of significance to the NFPB in particular and to the wider community in general as it heralds the beginning of the twenty-first century and the realization of the goals of Jamaica's National Population Policy. It also comes at the beginning of the gradual phased withdrawal of contraceptive procurement assistance by the major funding agency, the United States Agency for International Development (USAID), by a twenty percent (20%) annual decline over the period 1993-1998 under the Family Planning Initiatives Project (FPIP). In addition, there will be a phased diminution of funding from other lending agencies such as the United Nations Population Fund (UNFPA). This CPS is in fact one of two surveys to be conducted during the five-year span of the FPIP. Against this background, the NFPB has many challenges ahead which are, inter alia, not only to maintain but also to increase contraceptive prevalence and to achieve further milestones by the inception of the twenty-first century, such as a population of not more than 2.7 million and replacement level fertility of two children per woman. For contraceptive methods and family life services to have an impact on fertility and contribute to the processes of national development, it is vital that programme effectiveness be evaluated. The reliable and current data collected from the CPS will be of invaluable use to administrators and planners as they analyse policy and implement programmes, not only in health but in those areas which impact on population issues at the broader national level. The Final Report of the 1993 CPS is presented in the following five volumes: I Administrative Report II Knowledge Of and Attitudes Towards Family, Contraception and AIDS III Sexual Experience, Contraceptive Practice and Reproduction IV Sexual Behaviour and Contraceptive Use Among Young Adults V Profiles of Health Regions In addition, there is an Executive Summary that contains a summary of the main findings of the Survey. Volume I, the Administrative Report, contains background information on historical, geographical, demographic, and social features relating to Jamaica and its population as well as the relationship of the Survey data to the population policies and programmes being implemented by the Government. This volume also presents the survey design and organization, the sample design, and the outcomes of the data collection. Background variables used in the exposition of the data are also displayed. Finally, Volume I includes a summary report on the National Dissemination Seminar together with recommendations made by the participants. Volume II presents data on knowledge and attitudes of women aged 15-44 years and men aged 15-54 years towards family, contraception, and AIDS. Volume III contains information on sexual experience, contraceptive practice, and reproductive history. Volume IV is dedicated to young adults, female and male, aged 15-24 years and in particular to their sexual behaviour and contraceptive use. Jamaica is divided into three counties: Cornwall in the west, Middlesex in the central area and Surrey in the east. There are fourteen parishes: Kingston, St. Andrew, St. Thomas and Portland in the county of Surrey; St. Mary, St. Ann, Manchester, Clarendon and St. Catherine in the county of Middlesex; and Trelawny, St. James, Hanover, Westmoreland and St. Elizabeth in the county of Cornwall. In addition to these divisions, a number of administrative areas have been defined and used for various purposes, including the breakdown into health regions. The Health Regions are shown on the map on the page following this preface and are currently comprised of the following parishes: Region 1 Kingston, St. Andrew, St. Thomas and St. Catherine; Region 2 Portland, St. Mary and St. Ann; Region 3 Trelawny, St. James, Hanover and Westmoreland; Region 4 St. Elizabeth, Manchester and Clarendon. This volume, Volume V, presents the survey data by Health Region for each of the four Health Regions, so as to be able to determine the success or otherwise of the programmes being implemented in each of the four Health Regions. In March 1994 special workshops were conducted in each Health Region to present these data to program managers. The 1993 CPS was funded by US AID and directed by Mrs. Carmen McFarlane, Survey Director, a former Director General of the Statistical Institute of Jamaica (STATIN), in collaboration with the National Family Planning Board and the Ministry of Health, while field work and data entry were carried out by STATIN. Technical assistance was provided by the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC) in the areas of survey design and sampling, questionnaire development and training, data processing, and report preparation. STATIN and CDC were jointly responsible for printing. The National Family Planning Board wishes to place on record its sincere thanks to all those organizations that participated in planning the Survey, developing the questionnaire, and reviewing the various modules. Main participants were the Ministry of Health, the Statistical Institute of Jamaica, the Planning Institute of Jamaica, and the Fertility Management Unit of the University of the West Indies. Special acknowledgements are due to Mr. Vernon James, Director General, STATIN, for his leadership and support of STATIN'S participation in the Survey; Miss Isbeth Bernard, Director of Surveys, for supervision of the field work and data entry, Mrs. Valerie Nam, Director of Censuses & Related Studies and Mrs. Merville Anderson, Senior Statistician, for their assistance in training on the questionnaires, all of STATIN; and to Ms. Margaret Watson and Mr. Daniel Wallace, computer specialists of CDC, for installation of the data entry/edit software and training of STATIN personnel in its use. The NFPB also wishes to thank all who participated in the development, implementation and finalization of the survey. Particular mention is made of Mrs. Carmen McFarlane, Survey Diretor; Dr. Leo Morris and Mr. Jay Friedman of CDC; Mrs. Betsy Brown, Director, Office of Health, Nutrition and Population and Mrs. Grace Ann Grey, Project Officer, both of USAID; Dr. Shelia Campbell-Forrester, SMO, Cornwall Regional Hospital, Dr. Beryl Irons, SMO/MCH, Drs. Peter Figueroa of the Epidemiology Unit and Ms. Kristin Fox, Director, Health and Information Unit, of MOH; Dr. Olivia McDonald, Medical Director, Mrs. Eugenia McFarquhar, Family Planning Co-ordinator, Mrs. Ellen Radlein, Director, Projects & Research, Mrs. Janet Davis, Director, Information, Education & Communication, and Mrs. Marian Kenneally, Programme Co- ordinator, of the NFPB. Finally, to the more than 7,000 women and men who gave up their time to answer so many questions, we owe a debt of gratitude for this information, which we are sure will be useful in enhancing their lives. Beryl Chevannes Executive Director December 1994 CONTRACEPTIVE PREVALENCE SURVEY: JAMAICA 1993 SUMMARY OF RESULTS BY HEALTH REGION Table of Contents PREFACE MAP OF HEALTH REGIONS HEALTH REGION 1 SUMMARY . . . 1 Introduction . 1 Fertility . 4 Planning Status of the Last Pregnancy . 6 Knowledge of Contraceptives. 6 Contraceptive Use. 9 Condom Use . 16 Opinions On Contraception And Fertility . 21 Contraceptive Source . 21 The Need For Family Planning Services . 27 Young Adults. 27 HEALTH REGION 2 SUMMARY. 39 Introduction . 39 Fertility . 42 Planning Status of the Last Pregnancy . 44 Knowledge of Contraceptives . 44 Contraceptive Use. 47 Condom Use . 54 Opinions On Contraception And Fertility . 59 Contraceptive Source . 59 The Need For Family Planning Services . 65 Young Adults. 65 HEALTH REGION 3 SUMMARY . 77 Introduction . 77 Fertility . 80 Planning Status of the Last Pregnancy. 82 Knowledge of Contraceptives . 82 Contraceptive Use . . 85 Condom Use. . 92 Opinions on Contraception and Fertility . 97 Contraceptive Source . 97 The Need For Family Planning Services. 103 Young Adults . 103 HEALTH REGION 4 SUMMARY .115 Introduction . , . . . . . . . . . . . 115 Fertility. 118 Planning Status of the Last Pregnancy .120 Knowledge of Contraceptives .120 Contraceptive Use . . . . . . . 123 Condom Use . 131 Opinions On Contraception And Fertility .131 Contraceptive Source. 137 The Need For Family Planning Services .137 Young Adults . 141 1993 JAMAICA CONTRACEPTIVE PREVALENCE SURVEY HEALTH REGION 1 SUMMARY Introduction This summary presents the findings for Health Region 1 of the contraceptive prevalence survey (CPS) carried out in Jamaica in 1993. A previous survey of the same type was carried out in 1989. The 1993 CPS, therefore, not only provides data on the current situation in Health Region 1 and in Jamaica as a whole regarding contraceptive practices, but also permits an evaluation of the changes that have taken place since 1989. The 1993 CPS utilized an updated sampling frame based on the 1991 census which has been adopted for the Continuous Social and Demographic Surveys conducted by the Statistical Institute of Jamaica (STATIN). There are differences in the coverage of the two surveys. Whereas in the 1989 CPS women aged 15 to 49 were interviewed, the 1993 CPS excluded women aged 45 to 49. There was also an independent sample of men aged 15 to 54 in the 1993 CPS. For females, all comparisons in this report between the results of the two surveys have taken the coverage difference into account. When presented here, the results for 1989 have been adjusted by excluding the 45 to 49 year old women in that survey, to permit a direct comparison with the results of the 1993 survey. The 1993 survey also had detailed questions in a special module addressed to young adults aged 15 to 24, and a sequence of questions on condom use, multiple sexual partners, and attitudes toward contraception which were addressed to all respondents. In addition, since the parishes which comprise Health Region 1 have changed since 1989, all comparisons between 1989 and 1993 will be based on Health Region 1 as it exists today. Figures 1 and 2 show the percent distribution of male and female respondents in Health Region 1 by age, educational attainment, socio-economic level, and religion. These data show that a greater proportion of women have had more than a primary education and a post-secondary education than men, and are more likely to report that they are affiliated with a church. Comparison of age, union status and educational attainment data with results from the most recent census estimates or previous survey data indicates that the sample is representative of the target population (See Volume I). Fertility Due to small sample size at the regional level it was not possible to calculate fertility rates by health region, so fertility data for Jamaica as a whole will be presented. The survey results show the total fertility rate (TFR) for the years 1990-1992 to be 3.0 births per woman (Figure 3). This is not a statistically significant change from the TFR of 2.9 births per woman found in the 1989 survey. Age-specific fertility rates are very similar for all age groups through 30-34 years of age. For ages 35-39 and 40-44 slight increases of about 10 per 1000 were noted. Not shown is that mean numbers of live births declined at ages 35-39 and 40-44, but remained virtually unchanged for all younger age groups. The failure of fertility to decline seems surprising, given the increase in reported contraceptive use by women in union (from 55 to 62 percent for the nation and 56 to 65 percent for Health Region 1) in the interval between the two surveys. However, when fertility is plotted against contraceptive prevalence, the TFR falls almost exactly where it is expected (i.e., a population with the contraceptive use level reported for Jamaica would be expected to have a TFR of about 2.9; see Volume III). Since the TFR according to the 1989 survey was lower than expected, it is possible that the apparent failure of fertility to decline in recent years is in reality a result of an underestimate of the 1989 TFR and/or due to an increase in prevalence principally accounted for by an increase in condom use. One may also speculate that if the 7 percentage points increase in use occurred during the latter part of the 1989-1993, we would see a lag between the increase in use and a decrease in fertility. Not shown in a graph or table is that there were only slight changes between 1989 and 1993 in most of the factors other than contraception that directly affect fertility: proportions of women in union, breastfeeding, postpartum amenorrhea, and resumption of sexual activity following a birth. Overall, 70 percent of female respondents were currently married or in union, compared with 68 percent in 1989. Among 15-19 year- olds, 35 percent were currently in union. Ninety-four percent of children born in the previous 24 months had been breastfed, down slightly from 96 percent in 1989, but the mean duration of breastfeeding, just over 12 months, was unchanged. The mean length of postpartum amenorrhea was 4.7 months. The mean number of months from birth until the resumption of sexual activity was 5.5 months, shorter than the 6.9 months found in 1989. The reporting of abortions, another factor that affects fertility levels, was not sufficient to calculate rates of induced abortion. Health Region 1 - Page - 4 - Planning Status of the Last Pregnancy Figure 4 shows the distribution of the planning status of the last pregnancy within the past five years for women aged 15-44 in Health Region 1 and Jamaica as a whole. A pregnancy is defined as "planned" if the woman wanted to become pregnant at the time she became pregnant. A pregnancy is "mistimed" if she wanted to become pregnant at a later date, and is "unwanted" if she did not want to have any more children. "Unintended" or unplanned pregnancies combine these latter two categories. Overall, only twenty-nine percent of pregnancies were reported by respondents in Health Region 1 to have been planned; the majority were unintended - 51 percent were mistimed and 18 percent unwanted. These percentages are similar to 1989 for the country as a whole, when 52 percent of pregnancies were reported to be mistimed and 18 percent were unwanted. The proportion of unwanted pregnancies increases with age and the number of live births. Conversely, mistimed pregnancies are concentrated among younger women and women with fewer live births, when women are more likely to have spacing failures. As might be expected, the proportion of planned pregnancies is higher and the proportion of mistimed pregnancies lower in the more stable unions. The percentage of planned pregnancies rises slightly with an increase in the socio-economic index, but there is no discernable pattern by education or frequency of church attendance. The great majority of last pregnancies to women who are sterilized were reported to be unwanted. This, no doubt, was one of their reasons for choosing surgical contraception. Given the relatively high level of contraceptive use by women in union in Jamaica as a whole and in Health Region 1, the percentage of unintended pregnancies is very high. A factor that may be contributing to this finding is that approximately one-half of women using the three major reversible methods discontinued use within one year; even if women/couples change methods, there may be then be periods of unprotected sexual activity. This could conceivably result in higher rates of pregnancy than would be anticipated, given reported levels of contraceptive use. (See Volume III, p. 15, for results and a discussion of contraceptive discontinuation.) Knowledge of Contraceptives Figure 5 shows "knowledge" of contraceptives among women. Knowledge here refers Health Region 1 - Page - 6 - to the fact that the respondent has heard of a contraceptive method, not necessarily that he or she has enough knowledge of the method to be able to use it correctly. Virtually all women have heard of the condom, pill, injectable and female sterilization, and almost 90 percent know of the IUD. More than three-fourths of women have heard of the withdrawal method. The diaphragm, vaginal methods, natural methods, and Norplant, which are little used in Jamaica, are much less well known. While the informed choice of a contraceptive method must be left to the couple, lack of knowledge of some of the more effective methods, particularly vasectomy and the implant (Norplant), reduces the choice and potential use of some available long-term methods. With the exception of withdrawal and creams/jellies, the percentages of women having heard of all methods is virtually unchanged from 1989 to 1993. Among men (Figure 6), the best known methods are, as in the case of women, condoms, the pill, injectables, female sterilization (tubal ligation) and withdrawal. However, aside from withdrawal, all methods are less well known among men than among women. Contraceptive Use As in previous surveys, the data in this regional summary apply to the use of contraceptive methods as a primary method. New questions in the 1993 CPS on the use of secondary methods by men and women, and the use of contraception with secondary partners by men, was summarized in Volume III of the full national report. Figure 7 shows the prevalence of contraceptive use among women and men in union in Health Region 1 by principal type of method in 1993, comparing data for women with 1989. There has been a substantial increase in overall use by women from 56 percent to 65 percent during the four-year period. Most of this increase is accounted for by an increase in the use of condoms. The increase in the use of condoms from 8.9 percent of women in 1989 to 13.2 percent of women in 1993 undoubtedly reflects recent campaigns to increase condom use to prevent STD's and HIV infection. Men report a higher use of contraception (70%) than do women, primarily because of the high level of condom use by men. Figure 8 presents additional data on specific contraceptive method use by men and women in Health Region 1 in 1993. Oral contraceptives (20%) are the most prevalent method reported by women in union, followed by the condom (19%), female sterilization (13%) and injectables (7%). These are the same four leading methods as reported in 1989. Men in union report the condom (36%) as the most prevalent method followed by oral contraceptives (20%), female sterilization (7%) and injectables (3%). Men and women Health Region 1 - Page - 9 - report almost the same level of pill use, while women report a higher level of use of female sterilization than men. In Region 1 (and the rest of Jamaica) use of the IUD is relatively low. Some reasons for the differences in method-specific prevalence rates between men and women are: 1. lower reporting of male oriented methods by women; 2. males being ignorant of female use of injectables or tubal ligation and 3. that women in the survey are likely to be older than the partners of men in the male sample. Figure 9 presents contraceptive use reported by women in union, by major methods and by several selected socio-demographic characteristics. In general, as age and the number of live births increase, women tend to use more effective methods. While condom use predominates among women 19 and under (about half of these women using any method use the condom, the pill becomes the leading method used between 20 and 34 years of age. After age 35, the pill is in turn eclipsed by female sterilization as the major method; by age 40 more than three-fourths of women using any method are using surgical contraception. The pattern is similar as the number of live births increases. Overall contraceptive use by women in a marital union is at about the same level as women in common-law or visiting unions, but there is a major difference in the methods used by the different groups. More than half of those married women using any method have been surgically sterilized. In contrast, a much lower percentage (under 12 percent) of women in a common-law union or in a visiting relationship have been sterilized. A factor not evident in this figure is that a higher proportion of women who are married are older, compared with women in common-law and visiting unions, which in turn is correlated with the number of live births. As mentioned above, with increasing age and a greater number of live births, a greater proportion of women choose this permanent method. Women who are in less stable unions and who are younger and have fewer children tend to use pills and condoms to a greater extent. Although overall contraceptive use increases with more education and higher socio- economic level, except for a corresponding slight increase in condom use and slight drop in female sterilization, there is little pattern to the method mix for these two variables. Among men (Figure 10), patterns are similar to those of women except for a greater use of condoms by all sub-groups and an overall decrease in contraceptive use with age. This decrease is especially true of condom use since more than half of men under 25 are using condoms as their primary method, while only 15 percent of men over 44 are doing so. Pill use by the female partners of male respondents also falls with increasing age while female sterilization increases. As among women, there is a correspondent but less dramatic change in method mix according to the number of live births. Condom use increases dramatically and female sterilization decreases when unions are less stable. Overall use increases slightly with education, largely due to greater condom use. There is a similar pattern according to socio-economic level, mostly due to increased pill use. Health Region 1 - Page - 13 - To summarize the above findings, overall contraceptive use is high for all socio- demographic groups and the prevalence does not vary greatly by group. However, the choice of method does vary with age, with men and women moving from the condom to the pill and then to female sterilization as they get older. Figure 11 shows that half of all women have total confidence that the pill will prevent pregnancy and another 21 percent feel that the use of the pill poses only a slight risk of getting pregnant. Fewer men have this same degree of confidence in the pill; a total of only 30 percent of men feel there is no risk of pregnancy while using the pill. Since almost one-fourth of men report they don't know whether the pill is effective or not, compared to 12 percent of women, it may be assumed that women are basing their opinion on more direct experience with the pill than men. Although pill use is high in Jamaica and most women feel it is effective, almost thirty percent of women believe that the pill carries more than a slight risk of pregnancy or "don't know". This finding, along with the problem of pill compliance, justifies continuing education efforts. Sixty percent of women and more than 50 percent of men believe the pill to be completely safe or that it carries only a slight risk from the health point of view (Figure 12). However, almost one-fourth of both women and men believe the pill to be completely unsafe. Information on the benefits and risks of the pill are certainly needed in continuing education efforts. Condom Use Since condoms are an important method in Jamaica for both men and women, a special series of questions on condom use was addressed to all users of condoms, either as a primary or a secondary method, independent of their union status. Figure 13 shows that in Health Region 1, the majority of women and men who use condoms as a primary or secondary method do so both to prevent pregnancy and to protect themselves from sexually transmitted diseases. Relatively few use this method only as a disease prevention measure. Almost three-fourths of women, but only 41 percent of men, who report they are current users of condoms, use them all the time or all the time with certain partners (Figure 14). The use of this or of any method depends on correct and consistent use. Since the condom is the leading male method, used by more than one-third of men (Figure 8), the effective percentage of male users of condoms and of all methods is diminished by those who are using condoms inconsistently. Health Region 1 - Page - 16 - Opinions On Contraception And Fertility Figure 15 presents female and male opinions on the relative merits of male and female sterilization. Thirty-nine percent of women feel tubal ligation is the preferred method of sterilization, while only 16 percent of them think vasectomy is better. While a similar percentage of males think tubal ligation is superior, even fewer (4 percent) think vasectomy is better. Forty-five percent of women and most men think both methods of sterilization are equal or have no opinion. No Jamaican men were reported to have been sterilized in 1993 and only 0.1 percent reported use of vasectomy in 1989. Only 34 percent of women and a much lesser percentage of men, 15 percent, know when during the menstrual cycle a woman is most likely to get pregnant (Figure 16). Contraceptive Source Figure 17 displays the relative importance of the various sources of the four most prevalent contraceptive methods for men and women, and is compared with the 1989 CPS for women. There seems to have been a shift away from government health centers as a source for female pill and condom users since 1989. Most men obtain their condoms in pharmacies (41%), followed by shops and supermarkets (37%). Almost all female sterilizations are performed in hospitals, while a similar proportion of injectable contraceptives are obtained in health centers. The non-governmental sector, where contraceptives are purchased either on a social marketing or strictly commercial basis, may continue to increase. As seen in Figure 18, while about two-thirds of women and men already pay for their contraceptives, almost all who do not already pay for their contraceptive method report that they would be willing to do so. The percent distribution of the brands of condoms normally used is shown in Figure 19. The brand is important since each sector (government, social marketing, and strictly commercial) has its own. The government programme distributes Sultan, the social marketing programme sells Panther, while the strictly commercial sector sells Rough Rider and a number of lesser-used brands categorized here as "other". In Health Region 1, Panther, representing the social marketing sector, is the leading brand used by 34 percent of women and 40 percent of men. However, when Rough Rider and the "other" category are taken together, the strictly commercial sector condoms are sold to a greater extent than Panther. Almost one-fifth of women do not know the brand name of the condoms they use, since they are bought by their partners. Health Region 1 - Page - 21 - The Need For Family Planning Services In this report, women in need of family planning services are defined as women who are 1) sexually active, 2) fecund, 3) not currently pregnant, 4) who do not currently desire a child, and 5) are not using a contraceptive method. The definition for men in need of family planning services is that 1) the male respondent is sexually active, 2) the female partner is fecund, 3) the female partner is not currently pregnant, 4) the male respondent does not desire that his female partner become pregnant, and 5) neither the male respondent nor his partner is using a contraceptive method. Using this definition, 14 percent of women both in Health Region 1 and in Jamaica are in need of family planning services or are at risk of an unintended pregnancy (Figure 20). The need for family planning services increases from 12 percent of women with no live births to 18 percent of women with three live births, and then drops to 14 percent of women with four or more live births. Need for family planning services decreases with increasing education, and among those who profess a religion the need decreases with more frequent church attendance. In terms of union status, need is lowest among married women at 9 percent, and ranges from 12 to 25 percent of women in other union status categories. In Health Region 1, the need for family planning services is greater among men (19 percent) than women (14 percent) and shows less of a pattern by respondent characteristics (Figure 21). Need drops from 28 percent of the youngest men to 7 percent of men 50-54 years of age. As is the case for women, need is lowest among married men at 7 percent, but ranges as high as 34 percent of men with no steady partner. Young Adults The concern relating to the high levels of unintended adolescent pregnancies and childbirths has indicated that some special analysis of the problem should be attempted. A young adult module was therefore included in the 1993 CPS. As shown in Figure 22, the majority of young adult females in Health Region 1 believe that condoms (39%) or pills (35%) are the most appropriate contraceptive method for young people their age to use to prevent pregnancy. For young males, the overwhelming choice is the condom (78%). In Health Region 1, fewer young men are exposed to family life or sex education than are young women (Figure 23). Most respondents reported having family life or sex education courses in school only. Health Region 1 - Page - 27 - Sexual experience is defined as having sexual intercourse at least once. In this report, we focus on the first sexual experience and contraceptive behavior. Information relating to the current sexual activity (within the past month) and number of partners of young adults is presented in detail in Volume IV of the survey report. The proportion of young adults in Health Region 1 reporting sexual experience by age group is shown in Figure 24. Among the youngest females, the proportion is slightly higher, but not significantly different than the national figure and there has been an increase since 1989. For both males and females, as may be expected, sexual experience increases with age. The sexual experience rate for females at ages 15-17 is 46 percent. This figure increases to 81 percent in age group 18-19 and to 87 percent in the 20-24 age category. Sixty-seven percent of males aged 15-17 report sexual experience, while sexual experience is essentially universal for older males. In Health Region 1, less than half of young women and only 16 percent of young men used a contraceptive method at the time of their first sexual intercourse (Figure 25). Use of contraception is higher if the first partner was a boyfriend or girlfriend. The lower use with friends or casual acquaintances is doubly dangerous and not only risks an unintended pregnancy but may also put the young adult at risk of STDs, including HIV infection. Not shown in a graph is the reasons given for not using contraception at the time of first intercourse. In the nation as a whole, and in Health Region 1, the majority of young adults — 57 percent of females and 79 percent of males — did not use contraception at first sexual intercourse. When they were asked why not, almost one-half (47 percent) of females said that they did not expect to have sex at the time of first intercourse. Another 21 percent said that they did not have knowledge of contraception at the time of their first sexual experience (data not shown). The same is true for males but 34 percent of males said they didn't expect to have intercourse and 32 percent did not know about contraception at the time, reflecting the younger age of first intercourse for young males. In Health Region 1, the contraceptive methods used at first sexual experience are similar for both males and females (Figure 26). The overwhelming majority, more than eighty percent for each gender, report that they or their partner used condoms. The source of the contraception used at first intercourse in Health Region 1 differs somewhat for females and males (Figure 27). Females, who reported almost universally that their partner used a condom, gave the pharmacy as the primary source. Forty-one percent of males, who also largely used condoms at the time of their first intercourse, identified shops or markets as a primary source; in addition, another 41 percent stated that they obtained their condom from other sources, mostly friends. Another difference is that 31 percent of females did not know where their partner obtained the condom. Health Region 1 - Page - 32 - 1993 JAMAICA CONTRACEPTIVE PREVALENCE SURVEY HEALTH REGION 2 SUMMARY Introduction This summary presents the findings for Health Region 2 of the contraceptive prevalence survey (CPS) carried out in Jamaica in 1993. A previous survey of the same type was carried out in 1989. The 1993 CPS, therefore, not only provides data on the current situation in Health Region 2 and in Jamaica as a whole regarding contraceptive practices, but also permits an evaluation of the changes that have taken place since 1989. The 1993 CPS utilized an updated sampling frame based on the 1991 census which has been adopted for the Continuous Social and Demographic Surveys conducted by the Statistical Institute of Jamaica (STATIN). There are differences in the coverage of the two surveys. Whereas in the 1989 CPS women aged 15 to 49 were interviewed, the 1993 CPS excluded women aged 45 to 49. There was also an independent sample of men aged 15 to 54 in the 1993 CPS. For females, all comparisons in this report between the results of the two surveys have taken the coverage difference into account. When presented here, the results for 1989 have been adjusted by excluding the 45 to 49 year old women in that survey, to permit a direct comparison with the results of the 1993 survey. The 1993 survey also had detailed questions in a special module addressed to young adults aged 15 to 24, and a sequence of questions on condom use, multiple sexual partners, and attitudes toward contraception which were addressed to all respondents. In addition, since the parishes which comprise Health Region 2 have changed since 1989, all comparisons between 1989 and 1993 will be based on Health Region 2 as it exists today. Figures 1 and 2 show the percent distribution of male and female respondents in Health Region 2 by age, educational attainment, socio-economic level, and religion. These data show that a greater proportion of women have had more than a primary education and a post-secondary education than men, and are more likely to report that they are affiliated with a church. Men also report slightly higher socio-economic levels. A comparison of age, union status and educational attainment data with results from the most recent census estimates or previous survey data indicates that the sample is representative of the target population (See Volume I). Health Region 2 - Page - 39 - Fertility Due to the small sample size at the regional level, it was not possible to calculate fertility rates by health region, so fertility data for Jamaica as a whole will be presented. The survey results show the total fertility rate (TFR) for the years 1990-1992 to be 3.0 births per woman (Figure 3). This is not a statistically significant change from the TFR of 2.9 births per woman found in the 1989 survey. Age-specific fertility rates are very similar for all age groups through 30-34 years of age. For ages 35-39 and 40-44 slight increases of about 10 per 1000 were noted. Not shown is that mean numbers of live births declined at ages 35-39 and 40-44, but remained virtually unchanged for all younger age groups. The failure of fertility to decline seems surprising, given the substantial increase in reported contraceptive use by women in union (from 55 to 62 percent for the nation as well as for Health Region 2) in the interval between the two surveys. However, when fertility is plotted against contraceptive prevalence, the TFR falls almost exactly where it is expected (i.e., a population with the contraceptive use level reported for Jamaica would be expected to have a TFR of about 2.9); (See Volume III). Since the TFR according to me 1989 survey was lower than expected, it is possible that the apparent failure of fertility to decline in recent years is in reality a result of an underestimate of the 1989 TFR and/or due to an increase in prevalence principally accounted for by an increase in condom use. One may also speculate that if the 7 percentage points increase in use occurred during the latter part of the 1989-1993, we would see a lag between the increase in use and a decrease in fertility. Not shown in a graph or table is that there were only slight changes between 1989 and 1993 in most of the factors other than contraception that directly affect fertility: proportions of women in union, breastfeeding, postpartum amenorrhea, and resumption of sexual activity following a birth. Overall, 70 percent of female respondents were currently married or in union, compared with 68 percent in 1989. Among 15-19 year- olds, 35 percent were currently in union. Ninety-four percent of children born in the previous 24 months had been breastfed, down slightly from 96 percent in 1989, but the mean duration of breastfeeding, just over 12 months, was unchanged. The mean length of postpartum amenorrhea was 4.7 months. The mean number of months from birth until the resumption of sexual activity was 5.5 months, shorter than the 6.9 months found in 1989. The reporting of abortions, another factor that affects fertility levels, was not sufficient to calculate rates of induced abortion. Health Region 2 - Page - 42 - Planning Status of the Last Pregnancy Figure 4 shows the distribution of the planning status of the last pregnancy within the past 5 years for women aged 15-44 in Health Region 2 and Jamaica as a whole. A pregnancy is defined as "planned" if the woman wanted to become pregnant at the time she became pregnant. A pregnancy is "mistimed" if she wanted to become pregnant at a later date, and is "unwanted" if she did not want to have any more children. "Unintended" or unplanned pregnancies combine these latter two categories. Overall, only thirty percent of pregnancies were reported by respondents in Health Region 2 to have been planned; the majority were unintended -- 43 percent were mistimed and 23 percent unwanted. In 1989 for the country as a whole, 52 percent of pregnancies were reported to be mistimed and 18 percent were unwanted. The proportion of unwanted pregnancies increases with age and the number of live births. Conversely, mistimed pregnancies are concentrated among younger women and women with fewer live births, when women are more likely to have spacing failures. As might be expected, the proportion of planned pregnancies is higher and the proportion of mistimed pregnancies lower in the more stable unions. The percentage of planned pregnancies is higher among women with a post-secondary education and also rises with an increase in the socio-economic index and the frequency of church attendance. The great majority of last pregnancies to women who are sterilized were reported to be unwanted. This, no doubt, was one of their reasons for choosing surgical contraception. Given the relatively high level of contraceptive use by women in union in Health Region 2 and in Jamaica, the percentage of unintended pregnancies is very high. A factor that may be contributing to this finding is that approximately one-half of women using the three major reversible methods discontinued use within one year; even if women/couples change methods, there may be then be periods of unprotected sexual activity. This could conceivably result in higher rates of pregnancy than would be anticipated, given reported levels of contraceptive use. (See Volume III, p. 15, for results and a discussion of contraceptive discontinuation.) Knowledge of Contraceptives Figure 5 shows "knowledge" of contraceptives among women. Knowledge here refers to the fact that the respondent has heard of a contraceptive method, not necessarily that Health Region 2 - Page - 44 - he or she has enough knowledge of the method to be able to use it correctly. Virtually all women have heard of the condom, pill, injectable and female sterilization, and almost 90 percent know of the IUD. More than three-fourths of women have heard of the withdrawal method. The diaphragm, vaginal methods, natural methods and Norplant, which are little used in Jamaica, are much less known. While the informed choice of a contraceptive method must be left to the couple, lack of knowledge of some of the more effective methods, particularly vasectomy and the implant (Norplant), reduces the choice and potential use of some available long-term methods. The percentages of those who have heard of all methods is slightly higher in 1993 compared to 1989. Among men (Figure 6), the best known methods are, as in the case of women, condoms, the pill, injectables, and female sterilization. However, all methods are less well known among men than among women. Contraceptive Use As in previous surveys, the data in this regional summary apply to the use of contraceptive methods as a primary method. New questions in the 1993 CPS on the use of secondary methods by men and women, and the use of contraception with secondary partners by men was summarized in Volume III of the full national report. Figure 7 shows the prevalence of contraceptive use in Health Region 2 among women and men in union by principal type of method in 1993, comparing data for women with 1989. There has been a substantial increase in overall use by women from 55 percent to 62 percent during the four-year period. Most of this increase is accounted for by an increase in the use of condoms, as well as a smaller increase in the use of pills. The proportion of women using female sterilization in Health Region 2 has not changed since 1989. The increase in the use of condoms from 9.5 percent of women in 1989 to 15.5 percent of women in 1993 undoubtedly reflects recent campaigns to increase condom use to prevent STD's and HIV infection. Men report an overall level of contraceptive use (61%) that is similar to women, although their use of condoms is much higher. Figure 8 presents additional data on specific contraceptive method use by men and women in Health Region 2 in 1993. Oral contraceptives (24%) are the most prevalent method reported by women in union, followed by the condom (16%), female sterilization (13%) and injectables (6%). These are the same four leading methods as reported in 1989, although female sterilization use was then higher than condom use. Men in union report the condom (29%) as the most prevalent method followed by oral contraceptives (19%) and sterilization (10%). Women report a higher level of pill use than men and a slightly higher higher level of use of female sterilization than men. In Health Region 2 - Page - 47 - Region 2 (and the rest of Jamaica) use of the IUD is relatively low. Some reasons for the differences in method-specific prevalence rates between men and women are: 1. lower reporting of male oriented methods by women; 2. males being ignorant of female use of pills or tubal ligation and 3. that women in the survey are likely to be older than the partners of men in the male sample. Figure 9 presents contraceptive use reported by women in union, by major methods and by several selected socio-demographic characteristics. In general, as age and the number of live births increase, women tend to use more effective methods. While condom use predominates among women 19 and under (more than half of these women using any method use the condom), the pill becomes the major method used between 20 and 34 years of age. After age 35, the pill is in turn eclipsed by female sterilization as the major method; by age 40, three-fourths of women using any method are using female sterilization. The pattern is similar as the number of live births increases. Overall contraceptive use by women in a marital union is slightly higher than by women in common-law or visiting unions, and there is also a major difference in the method mix. Close to half of those married women using any method have been surgically sterilized (28 percent). In contrast, less than 10 percent of women in a common-law union or in a visiting relationship have been sterilized. A factor not evident in this figure is that a higher proportion of women who are married are older, compared with women in common law and visiting unions, which in turn is correlated with the number of live births. As mentioned above, with increasing age and a greater number of live births, a greater proportion of women choose this permanent method. Women who are in less stable unions and who are younger and have fewer children tend to use pills and condoms to a greater extent. Although overall contraceptive use increases with higher socio-economic level, except for a corresponding slight decrease in sterilization use, there is little pattern found in the method mix for this variable. There is little pattern seen in contraceptive use by education. Among men in Health Region 2 (Figure 10), patterns are similar to those of women except for a greater use of condoms by most sub-groups and an overall decrease in contraceptive use after age 24. This decrease is especially true of condom use since more than half of men under 30 are using condoms as their primary method, while only 12 percent of men over 44 are doing so. Pill use by the female partners of male respondents also falls from age 35 while female sterilization increases. As among women, there is a correspondent change in method mix as the number of live births increases. Following the progression from more stable to less stable unions, condom use increases dramatically and female sterilization decreases. Overall contraceptive use increases with education, but there is little pattern to use by socio-economic level. Health Region 2 - Page - 51 - To summarize the above findings, overall contraceptive use is high for all socio- demographic groups and the prevalence does not vary greatly by group. However, the choice of method does vary with age, with men and women moving from the condom to the pill and then to female sterilization as they get older. Figure 11 shows that more than half of all women have total confidence that the pill will prevent pregnancy and another 20 percent feel that the use of the pill poses only a slight risk of getting pregnant. Fewer men have this same degree of confidence in the pill; a total of only 31 percent of men feel there is no risk of pregnancy while using the pill. Since almost one-fourth of men report they don't know whether the pill is effective or not compared to 16 percent of women, it may be assumed that women are basing their opinion on more direct experience with the pill than men are. Although pill use is high in Jamaica and most women feel it is effective, almost one-third of women believe that the pill carries more than a slight risk of pregnancy or "don't know". This finding, along with the problem of pill compliance, justifies continuing education efforts. More than 50 percent of men and women believe that the pill is completely safe or that it carries only a slight risk from the health point of view (Figure 12). However, about one-fourth of both genders believe the pill to be completely unsafe. Information on the benefits and risks of the pill are certainly needed in continuing education efforts. Condom Use Since condoms are an important contraceptive method in Jamaica for both men and women, a special series of questions on their use was addressed to all users of condoms, either as a primary or a secondary method, independent of their union status. Figure 13 shows mat in Health Region 2 the majority of women and men who use condoms as a primary or secondary method do so to prevent pregnancy and also to protect themselves from sexually transmitted diseases. Relatively few use this method only as a disease prevention measure. Only 61 percent of women and 55 percent of men who report they are current users of condoms use them all the time or all the time with certain partners (Figure 14). The use of this or any method depends on correct and consistent use. Since the condom is the leading male method, used by almost 30 percent of men (Figure 8), the effective percentage of male users of condoms and of all methods is diminished by those who are using condoms inconsistently. Health Region 2 - Page - 54 - Opinions On Contraception And Fertility Figure 15 presents female and male opinions on the relative merits of male and female sterilization. Forty-four percent of women feel tubal ligation is the preferred method of sterilization, while only 13 percent of them think vasectomy is better. Fewer males think tubal ligation is superior and even fewer, 4 percent, think vasectomy is better. Two- thirds of men either think both methods of sterilization are equal or have no opinion on the matter. No Jamaican men were reported to have been sterilized in 1993 and only 0.1 percent reported use of vasectomy in 1989. Only 30 percent of women and an even lesser percentage of men, 21 percent, know when during the menstrual cycle a woman is most likely to get pregnant (Figure 16). Contraceptive Source Figure 17 displays the relative importance of the various sources of the four most prevalent contraceptive methods for men and women, and is compared with the 1989 CPS for women. There seems to have been little change in the source of contraception for women since 1989. A far greater proportion of men than women obtain their pills and condoms from private sources; that is, from shops and pharmacies. Almost all female sterilizations are performed in hospitals, while a similar proportion of injectable contraceptives are obtained from health centers. The non-governmental sector, where contraceptives are purchased either on a social marketing or strictly commercial basis, may continue to increase. As seen in Figure 18, while most women and men already pay for their contraceptives, almost all of the women and men who do not already pay for their contraceptive method report that they would be willing to do so. The percent distribution of the brands of condoms normally used is shown in Figure 19. The brand is important since each sector (government, social marketing, and strictly commercial) has its own. The government programme distributes Sultan, the social marketing programme sells Panther, and the strictly commercial sector sells Rough Rider and a number of lesser-used brands categorized here as "other". The social marketing condom, Panther, is the most widely used in Health Region 2; it is used by 31 percent of women and 39 percent of men. However, when Rough Rider and the "other" category are taken together, the strictly commercial sector condoms are sold to a slightly greater extent than Panther. Fifteen percent of women do not know the brand name of the condoms they use, since they are bought by their partners. Health Region 2 - Page – 59 – The Need For Family Planning Services In this report, women in need of family planning services are defined as women who are 1) sexually active, 2) fecund, 3) not currently pregnant, 4) who do not currently desire a child, and 5) are not using a contraceptive method. The definition for men in need of family planning services is that 1) the male respondent is sexually active, 2) the female partner is fecund, 3) the female partner is not currently pregnant, 4) the male respondent does not desire that his female partner become pregnant, and 5) neither the male respondent nor his partner is using a contraceptive method. Using this definition, 14 percent of women in Jamaica and 10 percent of women in Health Region 2 are in need of family planning services or are at risk of an unintended pregnancy (Figure 20). In Health Region 2, need drops from 14 percent of the youngest women to 4 percent in the oldest age group. The need for family planning services shows no pattern according to the number of live births. Need is lowest among women with only a primary education at 5 percent and increases to 20 percent of women with a post-secondary education. In Health Region 2, as shown in Figure 21 the need for family planning services is greater among men (22 percent) than women (10 percent). Need drops from 32 percent of the youngest men to a range of 12 to 22 percent of older men. The pattern is similar according to the number of live births. As is the case for women, need is lowest among married men at 7 percent, but ranges as high as 29 percent of men in a common-law union an 34 percent of men with no steady partner. Young Adults The concern relating to the high levels of unintended adolescent pregnancies and childbirths has indicated that some special analysis of the problem should be attempted. A young adult module, directing special questions toward respondents 15-24 years of age, was therefore included in the 1993 CPS. As shown in Figure 22, the majority of young adult females in Health Region 2 believe that condoms (39%) or pills (37%) are the most appropriate contraceptive method for young people their age to use to prevent pregnancy. For young males, the overwhelming choice is the condom (71%). In Health Region 2, a greater proportion of young women is exposed to family life or sex education than in the country as a whole (Figure 23). The same is true for young men, though to a lesser extent in the older age groups. Most respondents reported having family life or sex education courses in school only. Health Region 2 - Page - 65 - Sexual experience is defined as having sexual intercourse at least once. In this report, we focus on the first sexual experience and contraceptive behavior. Information relating to young adults and their current sexual activity (within the past month) and number of partners is presented in detail in Volume IV of the report of the survey. The proportion of young adults in Health Region 2 reporting sexual experience by age group is shown in Figure 24. Among the youngest females, the proportion reporting sexual experience is higher than the national figure and there has been a substantial increase since 1989. For both males and females, as may be expected, sexual experience increases with age. The sexual experience rate for females at ages 15-17 in Region 2 is 51 percent. This figure increases to 73 percent in age group 18-19 and is almost universal in the 20-24 age category. Seventy-four percent of males aged 15-17 report sexual experience, while sexual experience is essentially universal for males 18 years old and older. In Health Region 2, 48 percent of young women, but only 28 percent of young men, used a contraceptive method at the time of their first sexual intercourse (Figure 25). Use of contraception is higher if the first partner was a boyfriend or girlfriend. The lower use with friends or casual acquaintances is doubly dangerous and not only risks an unintended pregnancy but may also put the young adult at risk of STDs including HIV infection. Not shown in a graph are the reasons given for not using contraception at the time of first intercourse. In the nation as a whole, and in Health Region 2, the majority of young adults -- 57 percent of females and 79 percent of males -- did not use contraception at first sexual intercourse. When they were asked why not, almost one-half (47 percent) of females said that they did not expect to have sex at the time of first intercourse. Another 21 percent said that they did not have knowledge of contraception at the time of their first sexual experience (data not shown). The same is true for males but 34 percent of males said they didn't expect to have intercourse and 32 percent did not know about contraception at the time reflecting the younger age of first intercourse for males. In Health Region 2, the contraceptive methods used at first sexual experience are similar for both males and females (Figure 26). The overwhelming majority, more than eighty percent for each gender, report that they or their partner used condoms. The source of contraception used at first intercourse in Health Region 2 differs somewhat for females and males (Figure 27). Females, who reported almost universally that their partner used a condom, gave the pharmacy as the primary source. Thirty-six percent of males, who almost all also used condoms at the time of their first intercourse, identified shops or markets as a primary source; another 24 percent stated that they obtained their condom from other sources, mostly friends. Another difference is that almost 40 percent of females did not know where their partner obtained the condom. Health Region 2 - Page - 70 - 1993 JAMAICA CONTRACEPTIVE PREVALENCE SURVEY HEALTH REGION 3 SUMMARY Introduction This summary presents the findings for Health Region 3 of the contraceptive prevalence survey (CPS) carried out in Jamaica in 1993. A previous survey of the same type was carried out in 1989. The 1993 CPS, therefore, not only provides data on the current situation in Health Region 3 and in Jamaica as a whole regarding contraceptive practices, but also permits an evaluation of the changes that have taken place since 1989. The 1993 CPS utilized an updated sampling frame based on the 1991 census which has been adopted for the Continuous Social and Demographic Surveys conducted by the Statistical Institute of Jamaica (STATIN). There are differences in the coverage of the two surveys. Whereas in the 1989 CPS women aged 15 to 49 were interviewed, the 1993 CPS excluded women aged 45 to 49. There was also an independent sample of men aged 15 to 54 in the 1993 CPS. For females, all comparisons in this report between the results of the two surveys have taken the coverage difference into account. When presented here, the results for 1989 have been adjusted by excluding the 45 to 49 year old women in that survey, to permit a direct comparison with the results of the 1993 survey. The 1993 survey also had detailed questions in a special module addressed to young adults aged 15 to 24, and a sequence of questions on condom use, multiple sexual partners, and attitudes toward contraception which were addressed to all respondents. In addition, since the parishes which comprise Health Region 3 have changed since 1989, all comparisons between 1989 and 1993 will be based on Health Region 3 as it exists today. Figures 1 and 2 show the percent distribution of male and female respondents in Health Region 3 by age, educational attainment, socio-economic level, and religion. These data show that a greater proportion of women have had more than a primary education and a post-secondary education, and women are more likely to report that they are affiliated with a church. Comparison of age, union status and educational attainment data with results from the most recent census estimates or previous survey data indicates that the sample is representative of the target population (See Volume I). Health Region 3 - Page - 77 - Fertility Due to the small sample size at the regional level, it was not possible to calculate fertility rates by health region, so fertility data for Jamaica as a whole will be presented. The survey results show the total fertility rate (TFR) for the years 1990-1992 to be 3.0 births per woman (Figure 3). This is not a statistically significant change from the TFR of 2.9 births per woman found in the 1989 survey. Age-specific fertility rates are very similar for all age groups through 30-34 years of age. For ages 35-39 and 40-44 slight increases of about 10 per 1000 were noted. Not shown is that mean numbers of live births declined at ages 35-39 and 40-44, but remained virtually unchanged for all younger age groups. The failure of fertility to decline seems surprising, given the increase in reported contraceptive use by women in union (from 55 to 62 percent for the nation and 55 to 57 percent for Health Region 3) in the interval between the two surveys. However, when fertility is plotted against contraceptive prevalence, the TFR falls almost exactly where it is expected (i.e., a population with the contraceptive use level reported for Jamaica would be expected to have a TFR of about 2.9; See Volume III). Since the TFR according to the 1989 survey was lower than expected, it is possible that the apparent failure of fertility to decline in recent years is in reality a result of an underestimate of the 1989 TFR and/or due to an increase in prevalence principally accounted for by an increase in condom use. One may also speculate that if the 7 percentage points increase in use occurred during the latter part of the 1989-1993, we would see a lag between the increase in use and a decrease in fertility. Not shown in a graph or table is that there were only slight changes between 1989 and 1993 in most of the factors other than contraception that directly affect fertility: proportions of women in union, breastfeeding, postpartum amenorrhea, and resumption of sexual activity following a birth. Overall, 70 percent of female respondents were currently married or in union, compared with 68 percent in 1989. Among 15-19 year- olds, 35 percent were currently in union. Ninety-four percent of children born in the previous 24 months had been breastfed, down slightly from 96 percent in 1989, but the mean duration of breastfeeding, just over 12 months, was unchanged. The mean length of postpartum amenorrhea was 4.7 months. The mean number of months from birth until the resumption of sexual activity was 5.5 months, shorter than the 6.9 months found in 1989. The reporting of abortions, another factor that affects fertility levels, was not sufficient to calculate rates of induced abortion. Health Region 3 - Page - 80 - Planning Status of the Last Pregnancy Figure 4 shows the distribution of the planning status of the last pregnancy within the past five years for women aged 15-44 in Health Region 3 and Jamaica as a whole. A pregnancy is defined as "planned" if the woman wanted to become pregnant at the time she became pregnant. A pregnancy is "mistimed" if she wanted to become pregnant at a later date, and is "unwanted" if she did not want to have any more children. "Unintended" or unplanned pregnancies combine together these latter two categories. Overall, only thirty-two percent of pregnancies were reported by respondents in Health Region 3 to have been planned; the majority were unintended -- 41 percent were mistimed and 19 percent unwanted. These percentages are similar to 1989 for the country as a whole, when 52 percent of pregnancies were reported to be mistimed and 18 percent were unwanted. The proportion of unwanted pregnancies increases with age and the number of live births. Conversely, mistimed pregnancies are concentrated among younger women and women with fewer live births, when women are more likely to have spacing failures. As might be expected, the proportion of planned pregnancies is higher and the proportion of mistimed pregnancies lower in the more stable unions. The percentage of planned pregnancies rises somewhat with an increase in the socio-economic index and the frequency of church attendance, but there is no discernable pattern by education. The great majority of last pregnancies to women who are sterilized were reported to be unwanted. This, no doubt, was one of their reasons for choosing surgical contraception. Given the relatively high level of contraceptive use by women in union in Jamaica as a whole and in Health Region 3, the percentage of unintended pregnancies is very high. A factor that may be contributing to this finding is that approximately one-half of women using the three major reversible methods discontinued use within one year; even if women/couples change methods, there may be then be periods of unprotected sexual activity. This could conceivably result in higher rates of pregnancy than would be anticipated, given reported levels of contraceptive use. (See Volume III, p. 15, for results and a discussion of contraceptive discontinuation.) Knowledge of Contraceptives Figure 5 shows "knowledge" of contraceptives among women. Knowledge here refers to the fact that the respondent has heard of a contraceptive method, not necessarily that Health Region 3 - Page - 82 - he or she has enough knowledge of the method to be able to use it correctly. Virtually all women have heard of the condom, pill, injectable and female sterilization, and almost 80 percent know of the IUD. Almost three-fourths of women have heard of the withdrawal method. The diaphragm, vaginal methods, natural methods, and Norplant, which are little used in Jamaica, are much less known. While the informed choice of a contraceptive method must be left to the couple, lack of knowledge of some of the more effective methods, particularly vasectomy and the implant (Norplant), reduces the choice and potential use of some available long-term methods. The percentages having heard of all methods is virtually unchanged from 1989 to 1993. Among men (Figure 6), the best known methods are, as in the case of women, condoms, the pill, injectables, and female sterilization (tubal ligation). However, aside from condoms, all methods are less well known among men than among women. Contraceptive Use As in previous surveys, the data in this regional summary apply to the use of contraceptive methods as a primary method. New questions in the 1993 CPS on the use of secondary methods by men and women, and the use of contraception with secondary partners by men was summarized in Volume III of the full national report. Figure 7 shows the prevalence of contraceptive use among women and men in union in Health Region 3 by principal type of method in 1993, comparing data for women with 1989 data. There has been a slight increase in overall contraceptive use by women from 55 percent to 57 percent during the four-year period. Most of this increase is accounted for by an increase in the use of condoms and pills, although there has also been a slight increase in the use of female sterilization. The increase in the use of condoms from 9.5 percent of women in 1989 to 13.1 percent of women in 1993 undoubtedly reflects recent campaigns to increase condom use to prevent STD's and HIV infection. Men report a higher use of contraception (71%) than do women, primarily because of the high level of condom use by men. Figure 8 presents additional data on specific contraceptive method use by men and women in Health Region 3 in 1993. Oral contraceptives (24%) are the most prevalent method reported by women in union, followed by the condom (13 %), female sterilization (11%) and injectables (6%). These are the same four leading methods as reported in 1989. Men in union report the condom (33%) as the most prevalent method followed by oral contraceptives (23%), sterilization (7%), and injectables (6%). Men and women report the same level of pill use, but women report a higher level of female sterilization than Health Region 3 - Page - 85 - men. In Region 3 (and the rest of Jamaica) use of the IUD is relatively low. Some reasons for the differences in method-specific prevalence rates between men and women are: 1. lower reporting of male oriented methods by women; 2. males being ignorant of female use of tubal ligation and 3, that women in the survey are likely to be older than the partners of men in the male sample. Figure 9 presents contraceptive use reported by women in union by major methods and by several selected socio-demographic characteristics. In general, as age and the number of live births increase, women tend to use more effective methods. While condom use predominates among women 19 and under (more than half of these women using any method use the condom), the pill becomes the major method used between 20 and 34 years of age. After age 35, the pill is in turn eclipsed by female sterilization as the major method; by age 40 three-fourths of women using any method are using surgical contraception. The pattern is similar as the number of live births increases. Overall contraceptive use by women in a marital union is slightly higher than women in common-law or visiting unions and there is also a major difference in the method mix. Close to half of those married women using any method have been surgically sterilized (31 percent). In contrast, only 6 percent of women in a common-law union or in a visiting relationship have been sterilized. A factor not evident in this figure is that a higher proportion of women who are married are older, compared with women in common-law and visiting unions, which in turn is correlated with the number of live births. As mentioned above, with increasing age and a greater number of live births, a greater proportion of women choose this permanent method. Women who are in less stable unions and who are younger and have fewer children tend to use pills and condoms to a greater extent. Although overall contraceptive use increases with greater education and higher socio- economic level, except for a corresponding slight increase in condom use, there is little pattern found in the method mix for these two variables. Among men (Figure 10), patterns are similar to those of women except for a greater use of condoms by all sub-groups and an overall decrease in contraceptive use with age. This decrease is especially true of condom use since more than half of men under 25 are using condoms as their primary method, while only 13 percent of men over 44 are doing so. Pill use by the female partners of male respondents also falls with increasing age while female sterilization increases. As among women, there is a correspondent but less dramatic change in the method mix according to the number of live births. Going from more stable to less stable unions, condom use increases dramatically and female sterilization decreases. Overall use increases slightly with education, largely due to greater condom use, but there is little pattern to use by socio-economic level. Health Region 3 - Page - 89 - To summarize the above findings, overall contraceptive use is high for all socio- demographic groups and the prevalence does not vary greatly by group. However, the choice of method does vary with age, with men and women moving from the condom to the pill and then to female sterilization as they get older. Figure 11 shows that almost half of all women have total confidence that the pill will prevent pregnancy and another 21 percent feel that the use of the pill poses only a slight risk of getting pregnant. Fewer men have this same degree of confidence in the pill; a total of only 37 percent of men feel there is no risk of pregnancy while using the pill. Since one-fourth of men report they don't know whether the pill is effective or not, compared to 18 percent of women, it may be assumed that women are basing their opinion on more direct experience with the pill than men. Although pill use is high in Jamaica and most women feel it is effective, almost one-third of women believe that the pill carries more than a slight risk of pregnancy or "don't know". This finding, along with the problem of pill compliance, justifies continuing education efforts. Approximately 50 percent of both men and women believe that the pill is completely safe or that it carries only a slight risk from the health point of view (Figure 12). However, about one-fourth of both genders believe the pill to be completely unsafe. Information on the benefits and risks of the pill are certainly needed in continuing education efforts. Condom Use Since condoms are an important contraceptive method in Jamaica for both men and women, a special series of questions on their use was addressed to all users of condoms, either as a primary or a secondary method, independent of their union status. Figure 13 shows that in Health Region 3 the majority of women and men who use condoms as a primary or secondary method do so to prevent pregnancy and to protect themselves from sexually transmitted diseases. Relatively few use this method only as a disease prevention measure. Only 47 percent of women and 43 percent of men who report they are current users of condoms use them all the time or all the time with certain partners (Figure 14). The use of this or any method depends on correct and consistent use. Since the condom is the leading male method, used by one-third of men (Figure 8), the effective percentage of male users of condoms and of all methods is diminished by those who are using condoms inconsistently. Health Region 3 - Page - 92 - Opinions On Contraception And Fertility ■ , - . Figure 15 presents female and male opinions on the relative merits of male and female sterilization. One-third of women feel tubal ligation is the preferred method of sterilization, while only 5 percent of them think vasectomy is better. While a similar percentage of males think tubal ligation is superior, even fewer, 3 percent, think vasectomy is better. Most men and women think both methods of sterilization are equal or have no opinion. No Jamaican men were reported to have been sterilized in 1993 and only 0.1 percent reported use of vasectomy in 1989. Only 24 percent of women and a much lesser percentage of men, 10 percent, know when during the menstrual cycle a woman is most likely to get pregnant (Figure 16). Contraceptive Source Figure 17 displays the relative importance of the various sources of the four most prevalent contraceptive methods for men and women, and is compared with the 1989 CPS for women. There seems to have been a shift away from government health centers as a source for condom users since 1989. The largest source of condoms for men are shops and supermarkets, which are patronized by 44 percent of men using condoms. Almost all female sterilizations are performed in hospitals, while a similar proportion of injectable contraceptives are obtained in health centers. The non-governmental sector, where contraceptives are purchased either on a social marketing or strictly commercial basis, may continue to increase. As seen in Figure 18, while most women and men already pay for their contraceptives, almost all of the women and men who do not already pay for their contraceptive method report that they would be willing to do so. A percent distribution of the brands of condoms normally used is shown in Figure 19. The brand is important since each sector (government, social marketing, and strictly commercial) has its own. The government programme distributes Sultan, the social marketing programme sells Panther, while the strictly commercial sector sells Rough Rider and a number of lesser-used brands categorized here as "other". When Rough Rider and the "other" category are taken together, these strictly commercial sector condoms are sold to a greater extent than either Panther or Sultan. More than one-fourth of women do not know the brand name of the condoms they use, since they are bought by their partners. Health Region 3 - Page - 97 - The Need For Family Planning Services In this report, women in need of family planning services are defined as women who are 1) sexually active, 2) fecund, 3) not currently pregnant, 4) who do not currently desire a child, and 5) are not using a contraceptive method. The definition for men in need of family planning services is that 1) the male respondent is sexually active, 2) the female partner is fecund, 3) the female partner is not currently pregnant, 4) the male respondent does not desire that his female partner become pregnant, and 5) neither the male respondent nor his partner is using a contraceptive method. Using this definition, 14 percent of women in Jamaica and 16 percent of women in Health Region 3 are in need of family planning services or are at risk of an unintended pregnancy (Figure 20). In Health Region 3, need drops from 17 percent of the youngest women to 12 percent in the oldest age group. The need for family planning services increases from 13 percent for women with no live births to 19 percent of women with four or more live births. In terms of union status, need is lowest among married women at 8 percent and ranges from 16 to 24 percent of women in other union status categories or who have a boyfriend. In Health Region 3, the need for family planning services is greater among men (22 percent) than women (16 percent) and shows less of a pattern by socio-demographic characteristics (Figure 21). Need drops from 39 percent of the youngest men to a range of 9 to 28 percent of older men. The differences are similar according to the number of live births. As is the case for women, need is lowest among married men at 7 percent, but ranges as high as 39 percent of men with no steady partner. Young Adults The concern relating to the high levels of unintended adolescent pregnancies and childbirths has indicated that some special analysis of the problem should be attempted. A young adult module was therefore included in the 1993 CPS. As shown in Figure 22, the majority of young adult females in Health Region 3 believe that condoms (41%) or pills (31%) are the most appropriate contraceptive method for young people their age to use to prevent pregnancy. For young males, the overwhelming choice is the condom (71%). In Health Region 3, most respondents reported having family life or sex education courses in school only (Figure 23). Health Region 3 - Page - 103 - Sexual experience is defined as having sexual intercourse at least once. In this report, we focus on the first sexual experience and contraceptive behavior. Information relating to young adults on current sexual activity (within the past month) and number of partners is presented in detail in Volume IV of the report of the survey. The proportion of young adults in Health Region 3 reporting sexual experience by age group is shown in Figure 24. Among the youngest females, the proportion is higher than the national figure and there has been an increase since 1989. This figure is also statistically equal to males of the same age, the only Health Region in which this occurs. For both sexes, as may be expected, sexual experience increases with age. The sexual experience rate for females at ages 15-17 is 55 percent. This figure increases to 75 percent in age group 18-19 and to 89 percent in the 20-24 age category. Fifty-four percent of males aged 15-17 report sexual experience, while sexual experience is essentially universal for older males. In Health Region 3, most young adults did not use a contraceptive method at the time of their first sexual intercourse (Figure 25). There appears to be a striking difference between females and males in use of contraception at first intercourse. Females (31 percent) were much more likely than males (21 percent) to have used contraception. Contraceptive use is higher if the first partner was a boyfriend or girlfriend. The lower use with friends or casual acquaintances is doubly dangerous and not only risks an unintended pregnancy but may also put the young adult at risk of STDs, including HIV. Not shown in a graph are the reasons given for not using contraception at the time of first intercourse. In the nation as a whole, and in Health Region 3, the majority of young adults — 57 percent of females and 79 percent of males — did not use contraception at first sexual intercourse. They were asked why not? Almost one-half of females (47 percent) said that they did not expect to have sex at the time of first intercourse. Another 21 percent said that they did not have knowledge of contraception at the time of their first sexual experience (data not shown). The same is true for males but 34 percent of males said they didn't expect to have intercourse and 32 percent did not know about contraception at the time, reflecting the younger age of first intercourse for males. In Health Region 3 the contraceptive methods used at first sexual experience are similar for both males and females (Figure 26). The overwhelming majority, more than eighty percent for each gender, report that they or their partner used condoms. The sources of the contraception used at first sexual experience in Health Region 3 are similar for females and males (Figure 27). Females, who reported almost universally that their partner used a condom, gave the pharmacy, supermarket/shop and clinic/health center as the primary sources. Males, who also reported almost exclusive use condoms, also identified these three location as important sources; another 43 percent stated that they obtained their condom from other sources, mostly friends. Another difference is that about 40 percent of females did not know where their partner obtained the condom. Health Region 3 - Page - 108 - 1993 JAMAICA CONTRACEPTIVE PREVALENCE SURVEY HEALTH REGION 4 SUMMARY Introduction This summary presents the findings for Health Region 4 of the contraceptive prevalence survey (CPS) carried out in Jamaica in 1993. A previous survey of the same type was carried out in 1989. The 1993 CPS, therefore, not only provides data on the current situation in Health Region 4 and in Jamaica as a whole regarding contraceptive practices, but also permits an evaluation of the changes that have taken place since 1989. The 1993 CPS utilized an updated sampling frame based on the 1991 census which has been adopted for the Continuous Social and Demographic Surveys conducted by the Statistical Institute of Jamaica (STATIN). There are differences in the coverage of the two surveys. Whereas in the 1989 CPS women aged 15 to 49 were interviewed, the 1993 CPS excluded women aged 45 to 49. There was also an independent sample of men aged 15 to 54 in the 1993 CPS. For females, all comparisons in this report between the results of the two surveys have taken the coverage difference into account. When presented here, the results for 1989 have been adjusted by excluding the 45 to 49 year old women in that survey, to permit a direct comparison with the results of the 1993 survey. The 1993 survey also had detailed questions in a special module addressed to young adults aged 15 to 24, and a sequence of questions on condom use, multiple sexual partners, and attitudes toward contraception which were addressed to all respondents. In addition, since the parishes which comprise Health Region 4 have changed since 1989, all comparisons between 1989 and 1993 will be based on Health Region 4 as it exists today. Figures 1 and 2 show the percent distribution of male and female respondents in Health Region 4 by age, educational attainment, socio-economic level, and religion. These data show that a greater proportion of women have had more than a primary education and a post-secondary education than men, and are more likely to report that they are affiliated with a church. Comparison of age, union status and educational attainment data with results from the most recent census estimates or previous survey data indicates that the sample is representative of the target population (See Volume I). Health Region 4 - Page - 115 - Fertility Due to the small sample size at the regional level, it was not possible to calculate fertility rates by health region, so fertility data for Jamaica as a whole will be presented. The survey results show the total fertility rate (TFR) for the years 1990-1992 to be 3.0 births per woman (Figure 3). This is not a statistically significant change from the TFR of 2.9 births per woman found in the 1989 survey. Age-specific fertility rates are very similar for all age groups through 30-34 years of age. For ages 35-39 and 40-44 slight increases of about 10 per 1000 were noted. Not shown is that mean numbers of live births declined at ages 35-39 and 40-44, but remained virtually unchanged for all younger age groups. The failure of fertility to decline seems surprising, given the increase in reported contraceptive use by women in union (from 55 to 62 percent for the nation and 55 to 57 percent for Health Region 4) in the interval between the two surveys. However, when fertility is plotted against contraceptive prevalence, the TFR falls almost exactly where it is expected (i.e., a population with the contraceptive use level reported for Jamaica would be expected to have a TFR of about 2.9); (See Volume III). Since the TFR according to the 1989 survey was lower than expected, it is possible that the apparent failure of fertility to decline in recent years is in reality a result of an underestimate of the 1989 TFR and/or due to an increase in prevalence principally accounted for by an increase in condom use. One may also speculate that if the 7 percentage points increase in use occurred during the latter part of the 1989-1993, we would see a lag between the increase in use and a decrease in fertility. Not shown in a graph or table is that there were only slight changes between 1989 and 1993 in most of the factors other than contraception that directly affect fertility: proportions of women in union, breastfeeding, postpartum amenorrhea, and resumption of sexual activity following a birth. Overall, 70 percent of female respondents were currently married or in union, compared with 68 percent in 1989. Among 15-19 year- olds, 35 percent were currently in union. Ninety-four percent of children born in the previous 24 months had been breastfed, down slightly from 96 percent in 1989, but the mean duration of breastfeeding, just over 12 months, was unchanged. The mean length of postpartum amenorrhea was 4.7 months. The mean number of months from birth until the resumption of sexual activity was 5.5 months, shorter than the 6.9 months found in 1989. The reporting of abortions, another factor that affects fertility levels, was not sufficient to calculate rates of induced abortion. Health Region 4 - Page - 118 - Planning Status of the Last Pregnancy Figure 4 shows the distribution of the planning status of the last pregnancy within the past five years for women aged 15-44 in Health Region 4 and Jamaica as a whole. A pregnancy is defined as "planned" if the woman wanted to become pregnant at the time she became pregnant. A pregnancy is "mistimed" if she wanted to become pregnant at a later date, and is "unwanted" if she did not want to have any more children. "Unintended" or unplanned pregnancies combine together these latter two categories. Overall, only twenty-seven percent of pregnancies were reported by respondents in Health Region 4 to have been planned; the majority were unintended — 48 percent were mistimed and 23 percent unwanted. These percentages are similar to 1989 for the country as a whole, when 52 percent of pregnancies were reported to be mistimed and 18 percent were unwanted. The proportion of unwanted pregnancies increases with age and by the number of live births. Conversely, mistimed pregnancies are concentrated among younger women and women with fewer live births, when women are more likely to have spacing failures. As might be expected, the proportion of planned pregnancies is higher and the proportion of mistimed pregnancies lower in the more stable unions. The percentage of planned pregnancies rises with an increase in education and in the socio-economic index, but there is no discernable pattern by frequency of church attendance. The great majority of last pregnancies to women who are sterilized were reported to be unwanted. This, no doubt, was one of their reasons for choosing surgical contraception. Given the relatively high level of contraceptive use by women in union in Jamaica as a whole and in Health Region 4, the percentage of unintended pregnancies is very high. A factor that may be contributing to this finding is that approximately one-half of women using the three major reversible methods discontinued use within one year; even if women/couples change methods, there may be then be periods of unprotected sexual activity. This could conceivably result in higher rates of pregnancy than would be anticipated, given reported levels of contraceptive use. (See Volume III, p. 15, for results and a discussion of contraceptive discontinuation.) Knowledge of Contraceptives Figure 5 shows "knowledge" of contraceptives among women. Knowledge here refers to the fact that the respondent has heard of a contraceptive method, not necessarily that Health Region 4 - Page - 120 - he or she has enough knowledge of the method to be able to use it correctly. Virtually all women have heard of the condom, pill, injectable and female sterilization (tubal ligation), and almost 80 percent know of the IUD. Almost seventy percent of women have heard of the withdrawal method. The diaphragm, vaginal methods, natural methods and Norplant, which are little used in Jamaica, are much less known. While the informed choice of a contraceptive method must be left to the couple, lack of knowledge of some of the more effective methods, particularly vasectomy and the implant (Norplant), reduces the choice and potential use of some available long-term methods. The percentages having heard of all methods is virtually unchanged from 1989 to 1993. Among men (Figure 6), the best known methods are, as in the case of women, condoms, the pill, injectables, and female sterilization. However, aside from condoms and the pill, all methods are less well known among men than among women. Contraceptive Use As in previous surveys, the data in this regional summary apply to the use of contraceptive methods as a primary method. New questions in the 1993 CPS on the use of secondary methods by men and women, and the use of contraception with secondary partners by men was summarized in Volume III of the full national report. Figure 7 shows the prevalence of contraceptive use among women and men in union in Health Region 4 by principal type of method in 1993, comparing the data for women with data from 1989. There has been a slight increase in overall use by women from 56 percent to 59 percent during the four-year period. Most of this increase is accounted for by an increase in the use of condoms, although there has also been a slight increase in the use of pills. The higher use of condoms from 8.8 percent of women in 1989 to 16.1 percent of women in 1993 undoubtedly reflects recent campaigns to increase condom use to prevent STD's and HIV infection. Men report a higher use of contraception (74%) than do women, primarily because of the high level of condom use by men. Figure 8 presents additional data on specific contraceptive method use by men and women * in Health Region 4 in 1993. Oral contraceptives (22%) are the most prevalent method reported by women in union, followed by the condom (16%), female sterilization (12%) and injectables (5%). These are the same four leading methods as reported in 1989. Men in union report the condom (32%) as the most prevalent method followed by oral contraceptives (22%), sterilization (8%), and injectables (5%). Men and women report the same level of pill use, but women report a higher level of female sterilization than men. In Region 3 (and the rest of Jamaica) use of the IUD is relatively low. Health Region 4 - Page - 123 - Some reasons for the differences in method-specific prevalence rates between men and women are: 1. lower reporting of male oriented methods by women; 2. males being ignorant of female use of tubal ligation and 3. that women in the survey are likely to be older than the partners of men in the male sample. Figure 9 presents contraceptive use reported by women in union by major methods and by several selected socio-demographic characteristics. In general, as age and the number of live births increase, women tend to use more effective methods. While condom use predominates among women 19 and under (about two-thirds of women in this age group using any method use the condom), the pill becomes the major method used between 20 and 34 years of age. After age 35, the pill is in turn eclipsed by female sterilization as the major method; after age 40 three-fourths of women using any method are using surgical contraception. The pattern is similar as the number of live births increases. Overall contraceptive use by women in a marital union is similar to women in common- law or visiting unions, but there is a major difference in the method mix. The major method among married women is female sterilization (26 percent). In contrast, relatively few women in a common-law union or in a visiting relationship have been sterilized. A factor not evident in this figure is that a higher proportion of women who are married are older, compared with women in common-law and visiting unions, which in turn is correlated with the number of live births. As mentioned above, with increasing age and a greater number of live births, a greater proportion of women choose this permanent method. Women who are in less stable unions and who are younger and have fewer children tend to use pills and condoms to a greater extent. Among men (Figure 10), patterns are similar to those of women except for a greater use of condoms by all sub-groups and an overall decrease in contraceptive use after age 30. The proportion of pill users by the female partners of male respondents also falls after age 30 while female sterilization increases. As among women, there is a correspondent but less dramatic change in method mix according to the number of live births. Moving in the progression from more stable to less stable unions, condom use increases dramatically and female sterilization decreases. Overall use increases slightly by socio- economic level, but there is little pattern to use by education. To summarize, contraceptive use is high for all socio-demographic groups and usage levels do not vary greatly by group. However, the methods used do vary, with movement from the condom to the pill and to female sterilization with increasing age. Figure 11 shows that more than half of all women have total confidence that the pill will prevent pregnancy and another 19 percent feel that the use of the pill poses only a slight risk of getting pregnant. Fewer men have this same degree of confidence in the pill; a total of only 40 percent of men feel there is no risk of pregnancy while using the pill. Since more than one-fourth of men report they don't know whether the pill is effective Health Region 4 - Page - 127 - or not, compared to 17 percent of women, it may be assumed that women are basing their opinion on more direct experience with the pill than men. Although pill use is high in Jamaica and most women feel it is effective, 27 percent of women believe that the pill carries more than a slight risk of pregnancy or "don't know". This finding, along with the problem of pill compliance, justifies continuing education efforts. Exactly half of men and more than half of women believe the pill to be completely safe or that it carries only a slight risk from the health point of view (Figure 12). However, about one-fourth of both genders believe the pill to be completely unsafe. Information on the benefits and risks of the pill are certainly needed in continuing education efforts. Condom Use Since the condom is an important method in Jamaica for men and women, special questions on their use was addressed to all users of condoms, whether in union or not. Figure 13 shows that in Health Region 4 the majority of women and men who use condoms as a primary or secondary method do so to both prevent pregnancy and to protect themselves from sexually transmitted diseases. Relatively few use this method only as a disease prevention measure. Sixty-six percent of women and 47 percent of men who report they are current users of condoms, use them all the time or all the time with certain partners (Figure 14). The use of this or any method depends on correct and consistent use. Since the condom is the leading male method, used by one-third of men (Figure 8), the effective percentage of male users of condoms is diminished by those who are using condoms inconsistently. Opinions On Contraception And Fertility Figure 15 presents female and male opinions on the relative merits of male and female sterilization. Forty-five percent of women feel tubal ligation is the preferred method of sterilization, while only 12 percent prefer vasectomy. While a similar percentage of males think tubal ligation is superior even fewer, 3 percent, prefer vasectomy. More than half of men think both methods of sterilization are equal or have no opinion. No men were reported to have been sterilized in 1993 and only 0.1 percent so reported in 1989. Only 27 percent of women and a much lesser percentage of men, 9 percent, know when during the menstrual cycle a woman is most likely to get pregnant (Figure 16). Health Region 4 - Page - 131 - Contraceptive Source Figure 17 displays the relative importance of the various sources of the four most prevalent contraceptive methods for men and women, and is compared with the 1989 CPS for women. There seems to have been a shift away from government health centers as a source for pill users since 1989. The share of pharmacies has decreased and the share of shops has increased as a source of condoms for women. The largest source of condoms for men are shops and supermarkets, which are patronized by 38 percent of men using condoms, followed by health centers (36%). Almost all female sterilizations are performed in hospitals, while a similar proportion of injectable contraceptives are obtained in health centers. The non-governmental sector, where contraceptives are purchased either on a social marketing or strictly commercial basis, may continue to increase. As seen in Figure 18, while most women and men already pay for their contraceptives, all of women and almost all of men who do not already pay for their contraceptive method report that they would be willing to do so. The percent distribution of the brands of condoms normally used is shown in Figure 19. The brand is important since each sector (government, social marketing, and strictly commercial) has its own. The government programme distributes Sultan, the social marketing programme sells Panther, while the strictly commercial sector sells Rough Rider and a number of lesser-used brands categorized here as "other". In Health Region 4, Panther, the social marketing condom, is the leading brand used by women; however, when Rough Rider and the "other" category are taken together, the strictly commercial sector condoms are sold to a greater extent than Panther. Rough Rider, representing the strictly commercial sector, is the leading brand for men. Eleven percent of women do not know the brand name of the condoms they use, since they are bought by their partners. The Need For Family Planning Services In this report, women in need of family planning services are defined as women who are 1) sexually active, 2) fecund, 3) not currently pregnant, 4) who do not currently desire a child, and 5) are not using a contraceptive method. The definition for men in need of family planning services is that 1) the male respondent is sexually active, 2) the female partner is fecund, 3) the female partner is not currently pregnant, 4) the male respondent does not desire that his female partner become pregnant, and 5) neither the male Health Region 4 - Page - 137 - respondent nor his partner is using a contraceptive method. Using this definition, 14 percent of women in Jamaica and 13 percent of women in Health Region 4 are in need of family planning services or are at risk of an unintended pregnancy (Figure 20). In Health Region 4, need drops from 17 percent of the youngest women to 11 percent in the oldest age group. There is no clear pattern of need for family planning services according to number of live births. The need for family planning services increases as education and socio-economic levels increases, and decreases with greater frequency of church attendance. Among women in union, need is lowest among married women at 10 percent and is higher at 13 and 14 percent for women in common-law and visiting relationships. In Health Region 4, the need for family planning services is greater among men (20 percent) than women (13 percent) and shows less of a pattern by socio-demographic characteristics (Figure 21). Need drops from 38 percent of the youngest men to a range of 5 to 23 percent of older men. The differences are similar according to the number of live births. As is the case for women, need is lowest among married men at 9 percent, but ranges as high as 41 percent of men with no steady partner. Young Adults The concern relating to the high levels of unintended adolescent pregnancies and childbirths has indicated that some special analysis of the problem should be attempted. A young adult module was therefore included in the 1993 CPS. As shown in Figure 22, the majority of young adult females in Health Region 4 believe that condoms (43%) or pills (29%) are the most appropriate contraceptive method for young people their age to use to prevent pregnancy. For young males, the overwhelming choice is the condom (78%). In Health Region 4, a similar proportion of each gender have been exposed to family life or sex education as at the national level (Figure 23). A higher percentage of young women have had such courses than young men. Most respondents reported having family life or sex education courses in school only. Sexual experience is defined as having sexual intercourse at least once. In this summary, we focus on the first sexual experience and contraceptive behavior. Information relating to young adults on current sexual activity (within the past month) and number of partners is presented in detail in Volume IV of the report of the survey. The proportion of young adults in Health Region 4 reporting sexual experience by age Health Region 4 - Page - 141 - group is shown in Figure 24. Among the youngest females, the proportion appears to be much lower than the national figure and the proportion reported in 1989. However, due to the small sample size in this Health Region for this age group, the differences are not statistically significant. For both males and females, as may be expected, sexual experience increases with age. The sexual experience rate for females at ages 15-17 is 29 percent. This figure increases to 86 percent in age group 18-19 and is close to 100 percent in the 20-24 age category. Fifty-nine percent of males aged 15-17 report sexual experience, while sexual experience is essentially universal for older males. In Health Region 4, most young adults did not use a contraceptive method at the time of their first sexual intercourse (Figure 25). There appears to be a striking difference between females and males in use of contraception at first intercourse; females (45 percent) were much more likely than males (30 percent) to have used contraception. Among young women use of contraception is higher if the first partner was a boyfriend. The lower use with friends or casual acquaintances is doubly dangerous and not only risks an unintended pregnancy but may also put the young adult at risk of STDs including HIV infection. Among young men there is no clear pattern of contraceptive use according to the relationship with their first sexual partner. Not shown in a graph are the reasons given for not using contraception at the time of first intercourse. In the nation as a whole, and in Health Region 4, the majority of young adults - 57 percent of females and 79 percent of males - did not use contraception at first sexual intercourse. When they were asked why not, almost one-half of females (47 percent) said that they did not expect to have sex at the time of first intercourse. Another 21 percent said that they did not have knowledge of contraception at the time of their first sexual experience (data not shown). The same is true for males but 34 percent of males said they didn't expect to have intercourse and 32 percent did not know about contraception at the time, reflecting the younger age of first intercourse for young males. In Health Region 4 the contraceptive methods used at first sexual experience are similar for both males and females (Figure 26). The overwhelming majority, more than eighty percent for each gender, report that they or their partner used condoms. The sources of the contraception used at first sexual experience in Health Region 4 are similar for females and males (Figure 27). Females, who reported almost universally that their partner used a condom, gave the pharmacy, supermarket/shop, and clinic/health center as the primary sources. Males, who also reported almost exclusive use condoms, also identified these three location as sources; in addition, 46 percent stated that they obtained their condom from other sources, mostly friends. Another difference is that about 50 percent of females did not know where their partner obtained the condom. Health Region 4 - Page - 146 - Cover VOLUME V: SUMMARY OF RESULTS BY HEALTH REGION PREFACE Table of Contents 1993 JAMAICA CONTRACEPTIVE PREVALENCE SURVEY: HEALTH REGION 1 SUMMARY Introduction Fertility Planning Status of the Last Pregnancy Knowledge of Contraceptives Contraceptive Use Condom Use Opinions On Contraception And Fertility Contraceptive Source The Need For Family Planning Services Young Adults Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Figure 21 Figure 22 Figure 23 Figure 24 Figure 25 Figure 26 Figure 27 1993 JAMAICA CONTRACEPTIVE PREVALENCE SURVEY: HEALTH REGION 2 SUMMARY Introduction Fertility Planning Status of the Last Pregnancy Knowledge of Contraceptives Contraceptive Use Condom Use Opinions On Contraception And Fertility Contraceptive Source The Need For Family Planning Services Young Adults Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Figure 21 Figure 22 Figure 23 Figure 24 Figure 25 Figure 26 Figure 27 1993 JAMAICA CONTRACEPTIVE PREVALENCE SURVEY: HEALTH REGION 3 SUMMARY Introduction Fertility Planning Status of the Last Pregnancy Knowledge of Contraceptives Contraceptive Use Condom Use Opinions On Contraception And Fertility Contraceptive Source The Need For Family Planning Services Young Adults Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Figure 21 Figure 22 Figure 23 Figure 24 Figure 25 Figure 26 Figure 27 1993 JAMAICA CONTRACEPTIVE PREVALENCE SURVEY: HEALTH REGION 4 SUMMARY Introduction Fertility Planning Status of the Last Pregnancy Knowledge of Contraceptives Contraceptive Use Condom Use Opinions On Contraception And Fertility Contraceptive Source The Need For Family Planning Services Young Adults Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Figure 21 Figure 22 Figure 23 Figure 24 Figure 25 Figure 26 Figure 27

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