1993 CZECH REPUBLIC REPRODUCTIVE HEALTH SURVEY Final Report

Publication date: 1995

1993 CZECH REPUBLIC REPRODUCTIVE HEALTH SURVEY Final Report Czech Statistical Office Factum, non Fabula WHO Collaborating Center for Perinatal Medicine/ Institute for the Care of Mother and Child, Prague Centers for Disease Control and Prevention, USA March 1995 1993 CZECH REPUBLIC REPRODUCTIVE HEALTH SURVEY Final Report Czech Statistical Office Factum, non Fabula WHO Collaborating Center for Perinatal Medicine/ Institute for the Care of Mother and Child Centers for Disease Control and Prevention, USA March, 1995 ACKNOWLEDGEMENTS This report describes the 1993 Czech Republic Reproductive Health Survey (CRRHS) and its major findings. This nationwide undertaking could not have taken place without the involvement and cooperation of a large number of individuals and organizations in the Czech Republic and the United States. Funding for the survey was provided by the United States Agency for International Development (USAID/Washington). The survey was directed by Dr. Ivan Tomek and Mr. Jaroslav Kraus, who were responsible for coordinating many of the survey activities. Professor Zdenek Stembera, director of the World Health Organization Collaborating Center for Perinatal Medicine was the principal resource person for maternal and child health and administered the funds for the survey. Dr. Jitka Slavikova served as fieldwork coordinator. Drs. Howard Goldberg and Petr Velebil of the United States Centers for Disease Control and Prevention (CDC) provided technical assistance and consultation for all aspects of the survey. Mr. James Bednar and other staff members at USAID/Prague provided support to the survey in a number of ways. Besides these individuals and their organizations, there were many others that contributed to the many tasks necessary for successful completion of the survey, including administrative tasks, questionnaire development and review, training, field work/data collection, data processing, and analysis. This report was prepared by Howard Goldberg, Petr Velebil, Zdenek Stembera, Ivan Tomek, and Jaroslav Kraus. iii Contributors to the Survey The following organizations and individuals made important contributions to the success of the 1993 Czech Republic Health Survey: Dr. I. Tomek, Survey co-director Mr. J. Kraus, Survey co-director Mrs. J. Slavikova, Fieldwork coordinator Czech Statistical Office Mr. Edvard Outrata. President Mr. J. Fischer, CSc, Vice president Mrs. J. Ruzkova, CSc, Director, Vital Statistics Department Mr. J. Kraus, Vital Statistics Department Mr. J. Pecka, Programming Department Mrs. L. Zacharova, Technical Support Department Dr. B. Jungmann, CSc, Director, Public Opinion Research Institute (PORI) Dr. M. Vasickova, Interviewer supervisor, PORI Mrs. E. Sochorova, Interviewer supervisor, PORI Dr. J. Michalec, Survey Department, PORI Ms. V. Kobylkova, Survey Department, PORI J. Namestkova, A. Petraskova, M. Tyborova, PORI Data entry staff Interviewing staff Printing office FACTUM, non fabula Dr. I. Tomek, CSc. Dr. J. Slavikova Dr. J. Herzmann, CSc. Interviewing staff WHO Collaborating Center for Perinatal Medicine/Institute for the Care of Mother and Child Prof. MUDr. Z. Stembera, DrSc, Director, WHO Collaborating Center Czech Family Planning Association Dr. R. Uzel, CSc, Director, Czech Family Planning Association Dr. V. Wynnyczuk, CSc, Czech Family Planning Association v Ministry of Health Dr. M. Kosulicova, Chief, Department of Maternal and Child Health Dr. K. Ciharova, Chief, Department of International Cooperation Dr. I. Karaskova, Department of Maternal and Child Health Dr. V. Albrecht, CSc, Chief, WHO Collaborating Centers Activity Konsorcium Universitas Dr. P. Kuchar, CSc. Dr. J. Burianek, CSc. Interviewers Centers for Disease Control and Prevention. Division of Reproductive Health Dr. H. Goldberg, PhD., Deputy Chief, Behavioral Epidemiology and Demographic Research Branch Dr. P. Velebil, MD., Visiting Scientist Dr. L. Morris, PhD., Chief, Behavioral Epidemiology and Demographic Research Branch Ms. M. Watson, Chief, Computer Resources Section United States Agency for International Development/Prague Ms. L. Roussel, Country Representative Mr. J. Bednar, Project Manager Ms. E. Kostelkova, PhD., Project Specialist Ms. S. Strbanova, PhD., Project Specialist vi TABLE OF CONTENTS PAGE ACKNOWLEDGEMENTS. iii CONTRIBUTORS TO THE SURVEY .v LIST OF TABLES. xi LIST OF FIGURES. xxi SUMMARY . 1 CHAPTER I. INTRODUCTION/SURVEY METHODOLOGY. 12 Survey Background Organizational Structure Questionnaire Content Sample Selection Data Collection Data Entry/Editing Response Rates CHAPTER II. RESPONDENT CHARACTERISTICS .20 CHAPTER III. CHILDBEARING/ABORTION.35 Children Ever Born Current Fertility Timing of First Births Desired Number of Children Planning Status of Pregnancies Induced Abortions CHAPTER IV. FAMILY PLANNING .59 Knowledge of Methods for Preventing Pregnancy Ever Use of Contraception Current Use of Contraception Source of Contraception Reasons for Not Using Contraception Contraceptive Failure/Discontinuation vii PAGE Use of Less Effective Methods Need for Family Planning Services Problems with Current Contraceptive Methods Contraceptive Sterilization Use of Infertility Services CHAPTER V. PREGNANCY, DELIVERY, AND INFANT HEALTH . 97 Reaction to Pregnancy Physical Exertion/Stress during Pregnancy Prenatal Care Ultrasound Examinations Bed Rest/Hospitalization during Pregnancy Smoking during Pregnancy Birthweight/Pregnancy Outcomes Labor and Delivery Problems in the Post Partum Period Prenatal Counselling Breastfeeding CHAPTER VI. YOUNG ADULT SEXUAL BEHAVIOR.148 Initiation of Sexual Intercourse Contraception at First Intercourse Premarital Pregnancy Family Planning Discussions with Parents CHAPTER VII. REPRODUCTIVE HEALTH KNOWLEDGE AND ATTITUDES. 161 Attitudes about Restrictions on Abortion Knowledge of the Menstrual Cycle Opinions about Oral Contraceptives Women's Family and Reproductive Roles CHAPTER VIII. WOMEN'S HEALTH. 175 Gynecologic Examinations Breast Self Examination Cigarette Smoking Alcohol Consumption Overweight viii PAGE CHAPTER IX. TRANSMISSION OF HIV/AIDS.186 REFERENCES .190 APPENDIX A. SAMPLING ERRORS . 192 APPENDIX B. CRRHS QUESTIONNAIRE. 195 ix LIST OF TABLES CHAPTER I: INTRODUCTION/METHODOLOGY I.1 Final Interview Status, by Size of Place I.2 Region of Residence and Size of Place of Residence, 1993 Czech Republic Reproductive Health Survey Respondents and Women 15-44 Years Old in the 1991 Czech Republic Census CHAPTER II: RESPONDENT CHARACTERISTICS II.1 Comparison of Percent Distributions of Age and Marital Status according to the 1991 Czech Census and the 1993 Czech Republic Reproductive Health Survey II.2 Selected Sociodemographic Characteristics of Respondents, by Age Group II.3 Percent Distributions of Monthly Household Income, Employment Status of Respondents and Average Number of Hours Worked per Week II.4 Percent of Respondent Households with Various Possessions/Amenities and Percent Distribution of Number of Selected Possessions in Households II.5 Ownership of Residence, Number of Families Living in Residence and Number of People Living in Residence II.6 Husband's Education, Household Income, and Number of Selected Possessions, by Respondent's Education, Women 20 to 44 Years of Age II.7 Life Table Estimates of Percent of Women Ever in Union Before Ages 18, 20, and 25 and Median Age at First Union, by Selected Characteristics II.8 Percent of Women Ever in Union Who Are Still in Their First Marriage/Union, by Selected Characteristics, by Years since First Marriage/Union xi CHAPTER III: CHILDBEARING/ABORTION III.1 Total Number of Live Births, by Age and Years since Marriage III.2 Mean Number of Children Ever Born, by Age and Selected Characteristics III.3 Age-Specific Fertility Rates and Total Fertility Rates (TFR), 1993 Czech Republic Reproductive Health Survey and 1991 Vital Statistics III.4 Total Fertility Rates, by Selected Characteristics III.5 Life Table Estimates of Percent of Respondents with Any Live Births before Selected Ages and Median Age at First Birth, by Selected Characteristics III.6 Life Table Estimates of Percent of Respondents with Any Live Births before Selected Marriage Durations and Median Duration at First Birth, according to Current Age and Education of Respondent III.7 Number of Children Planned When Respondent First Married, by Selected Characteristics, Women Ever Married III.8 Number of Children Planned When Respondent First Married, by Total Number of Children Currently Planned, Fecund Respondents Currently in Union III.9 Percent of Respondents Reporting That They Want to Have No More Children, by Selected Characteristics, Fecund Married Respondents III.10 Number of Additional Children Desired, according to Current Number of Living Children, Fecund Women 15 to 44 Years of Age III.11 Planning Status of Pregnancies Ending after 1987 III.12 Outcomes of Reported Pregnancies Ending after 1987, according to Planning Status of Pregnancy xii III.13 Mean Number of Induced Abortions per Woman and Induced Abortions per 100 Known Conceptions, Based on Recent Official Statistics, Selected Countries of Central and Eastern Europe III.14 Reasons for Choosing to Have an Induced Abortion, for Abortions Taking Place after 1987 CHAPTER IV: FAMILY PLANNING IV.1 Percentage of Currently Married Respondents Familiar with Various Contraceptive Methods, by Education IV.2 Percentage of Currently Married Respondents Who Have Ever Used Various Contraceptive Methods, by Education IV.3 Percent of Currently Married Women Currently Using Any Contraceptive Method or Any Modern Method, by Selected Characteristics IV.4 Current Contraceptive Use, by Marital Status IV.5 Current Contraceptive Use, by Number of Living Children, Women Married or in Union IV.6 Current Contraceptive Use, by Age, Women Married or in Union IV.7 Current Contraceptive Use, by Education of Respondent, Women Married or in Union IV.8 Current Contraceptive Use, by Religion, Women Married or in Union IV.9 Current Contraceptive Use, by Whether Respondent Wants to Have Any More Children, Fecund, Nonpregnant Women Currently in Union IV.10 Source of Oral Contraceptives and lUDs, by Region, Current Users of Those Methods IV.11 Primary Reason for Not Using Contraception, by Marital Status IV.12 Percent of Women in Need of Family Planning Services, according to Two Definitions, by Selected Characteristics xiii IV.13 Importance of Selected Factors in Couples' Decisions to Use Traditional Methods of Contraception, Current Users of Traditional Methods IV.14 Percent of Current Users of Withdrawal or Natural Family Planning Who Reported that Selected Factors Were Very Important or Somewhat Important in the Selection of Their Contraceptive Method, by Age, Education, and Method IV.15 Opinions of Current Users of Withdrawal or Natural Family Planning regarding the Effectiveness of Their Current Method Relative to Modern Methods, by Age, Education, and Method IV.16 Most Important Problem or Concern with Current Contraceptive Method, according to Method Used IV.17 Preference for Current or Other Method, Current Contraception Users and Method Preferred among Women Preferring Another Method IV.18 Contraceptive Failure Rates, in Percents, for Selected Methods after 12, 24, and 36 Months, for Segments of Use Beginning after 1987 IV.19 Contraceptive Discontinuation Rates, in Percents, for Selected Methods after 12, 24, and 36 Months, for Segments of Use Beginning after 1987 IV.20 Most Important Reason for Discontinuing Use of Contraceptive Method according to Method Used, All Reported Segments of Use Beginning and Ending after 1987 IV21 Interest in Surgical Sterilization among Fecund Women Wanting No More Children, by Selected Characteristics IV.22 Primary Reason for Lack of Interest in Surgical Sterilization among Fecund Women Wanting No More Children, by Education IV.23 Profile of Respondents Who Have Been Surgically Sterilized, Compared to All Respondents IV.24 Use of Infertility Services according to When Services Were Last Received and Selected Characteristics, Women Ever in Union xiv IV.25 Percent of Respondents Receiving Selected Treatment/ Counselling among Those Who Visited a Physician or Clinic for Infertility Problems, by Place of Residence and Age When Services were Last Received CHAPTER V: PREGNANCY, DELIVERY, AND INFANT HEALTH V.1 Respondents' Reaction to Most Recent Pregnancy, by Selected Characteristics V.2 Spouse's/Partner's Reaction to Most Recent Pregnancy, by Selected Characteristics V.3 Amount of Physical Work During Most Recent Pregnancy, by Selected Characteristics V.4 Amount of Standing at Work During Most Recent Pregnancy, by Selected Characteristics V.5 Amount of Stress at Work During Most Recent Pregnancy, by Selected Characteristics V.6 Trimester When Prenatal Care Began During Most Recent Pregnancy, by Selected Characteristics V.7 Number of Prenatal Care Visits during Most Recent Pregnancy, by Selected Characteristics V.8 Who Provided the Most Prenatal Care during Most Recent Pregnancy, by Selected Characteristics V.9 Where most of Prenatal Care Was Provided during Most Recent Pregnancy, by Selected Characteristics V.10 Time Spent Travelling to the Place of Prenatal Care, by Means of Transportation V.11 Waiting Time for Prenatal Care during Most Recent Pregnancy, by Selected Characteristics V.12 Whether Respondent Received Ultrasound Examination during Most Recent Pregnancy, by Selected Characteristics xv V.13 Degree to Which the Purpose of Ultrasound Examination Was Explained, by Selected Characteristics V.14 Whether Bed Rest was Prescribed during Most Recent Pregnancy and Length of Bed Rest, by Selected Characteristics V.15 Hospitalization during Most Recent Pregnancy and Length of Stay, by Selected Characteristics V.16 Percent of Women Hospitalized during Most Recent Pregnancy for Whom Various Conditions Were Diagnosed, by Parity V.17 Smoking Status of Women during Most Recent Pregnancy, by Selected Characteristics V.18 Percent Babies with Low Birthweight, by Parity V.19 Outcomes of Intended Pregnancies Ending since January 1988, by Selected Characteristics V.20 Assessment of Characteristics of Place of Delivery, by Parity V.21 Length of Delivery Relative to Expected Length, by Selected Characteristics V.22 Pain during Labor Relative to Expected Pain, by Selected Characteristics V.23 Percent of Respondents Who Thought They Received Enough Information on Pregnancy, by Selected Characteristics, by Parity V.24 Percent of Respondents Who Thought They Received Enough Information on Delivery, by Selected Characteristics, by Parity V.25 Who the Respondent Would Like to have Present at Next Delivery, by Selected Characteristics V.26 Whether the Respondent Would be Interested in Delivery at Home, by Selected Characteristics V.27 Most Important Problems during the First Week after Delivery, by Selected Characteristics xvi V.28 Most Important Problems after Returning Home after Delivery, by Selected Characteristics V.29 Amount of Prenatal Counseling during the Most Recent Pregnancy, by Selected Characteristics V.30 Percent of Respondents' Children Born since January 1988 Who Were Breastfed, by Selected Characteristics V.31 Mean Duration of Breastfeeding for Children Born since January 1988, by Selected Characteristics CHAPTER VI: YOUNG ADULT SEXUAL BEHAVIOR VI.1 Life Table Estimates of Percent of Women Who Have Ever Had Sexual Intercourse before Given Ages and Median Age at First Intercourse, according to Age at Interview VI.2 Percent of Women 15 to 24 Years of Age Who Have Ever Had Sexual Intercourse, by Selected Characteristics and Age at Interview VI.3 Relationship to First Sexual Partner and Length of Relationship at the Time of First Sexual Intercourse, according to Age at First Sexual Intercourse, Sexually Experienced Females, 15 to 24 Years Old VI.4 Contraceptive Method Used at First Sexual Intercourse, by Selected Characteristics, Sexually Experienced Females, 15 to 24 Years Old VI.5 Reason for not Using a Contraceptive Method at the Time of First Sexual Intercourse by Age at First Sexually Experienced Females, 15 to 24 Years Old VI.6 Relationship to Partner at Time of First Pregnancy, Whether She Married That Man, and Attitude of Partner Regarding the Pregnancy by Age at First Pregnancy, Women 15 to 24 Years Old with Any Reported Premarital Pregnancies VI.7 Attitude of Respondent's Family Regarding Her First Pregnancy, by Age at First Pregnancy, Women 15 to 24 Years Old with Any Reported Premarital Pregnancies xvii VI.8 Age at Which Respondent's Parents First Discussed Family Planning Methods with Her, by Selected Characteristics, 15 to 24 Years Old Females CHAPTER VII: REPRODUCTIVE HEALTH KNOWLEDGE AND ATTITUDES VII.1 Percent of Respondents Who Think That Women Should Be Able to Decide Whether to Have an Abortion for Any Pregnancy, by Selected Characteristics VII.2 Opinions on Whether Women Should Be Able to Have an Abortion under Given Circumstances, among Respondents Who Think There Should Be Restrictions on Whether Women Can Have Abortions VII.3 Percent of Respondents Who Think That Women Should Be Able to Decide Whether to Have an Abortion under Selected Circumstances, by Selected Characteristics VII.4 Percent of Respondents with Correct Knowledge of When a Woman Is the Most Likely to Conceive during Her Menstrual Cycle, by Selected Characteristics VII.5 Opinions about the Reliability of Oral Contraceptives, by Selected Characteristics VII.6 Opinions about the Safety of Oral Contraceptives, by Selected Characteristics VII.7 Opinions regarding Various Statements Concerning Oral Contraceptives VII.8 Opinions regarding Various Statements Concerning Women's Roles and Reproduction CHAPTER VIII: WOMEN'S HEALTH VIII.1 Frequency of Receipt of Gynecologic Exams, by Region of Residence, Age, and Education VIII.2 Primary Reason for Receiving Gynecologic Exam Less Than Yearly xviii VIII.3 Knowledge and Use of Breast Self-Examination (BSE) by Selected Characteristics VIII.4 Current Cigarette Smoking Status, by Selected Characteristics VIII.5 Average Number of Cigarettes Smoked per Day, Selected Characteristics Women Who Currently Smoke VIII.6 Average Weekly Alcohol Consumption, by Selected Characteristics VIII.7 Percent of Respondents Who Are Substantially Overweight, by Selected Characteristics CHAPTER IX: TRANSMISSION OF HIV/AIDS IX.1 Percent of Respondents Who Think That the AIDS Virus Can Be Transmitted in Various Ways, by Education of Respondent IX.2 Opinions about the Effectiveness of Condoms in Protecting against HIV Infection, by Selected Characteristics IX.3 Respondents' Opinions about Their Own Risk of Contracting AIDS, by Selected Characteristics xix LIST OF FIGURES CHAPTER II: RESPONDENT CHARACTERISTICS I.1 Education of Respondents by Age Group II.2 Religion of Respondents by Age Group II.3 Percent of Respondent Households With Selected Possessions/ Amenities II.4 Percent Ever Married Before Selected Ages CHAPTER III: CHILDBEARING/ABORTION III.1 Total Fertility Rates, Selected Central and Eastern European Countries III.2 Fertility Rates, 20-24 Year-Old Women, Selected European Countries III.3 Fertility Rates, 30-34 Year-Old Women, by Selected European Countries III.4 Number of Additional Children Desired According to Number of Living Children, Fecund Women CHAPTER IV: FAMILY PLANNING IV.1 Current Contraceptive Use Among Married Women IV.2 Current Contraceptive Use Among Married Women by Number of Living Children IV.3 Importance of Selected Factors in Decision to Use Traditional Contraception IV.4 Interest in Surgical Sterilization Among Women Wanting No More Children by Number of Living Children xxi CHAPTER V: PREGNANCY, DELIVERY, AND INFANT HEALTH V.1 Percent of Respondents With No Prenatal Care During Their First Trimester, By Region V.2 Percent of Respondents With No Ultrasound Exam During Her Most Recent Pregnancy V.3 Selected Indicators and Aspects of Prenatal Care During Respondents' Most Recent Pregnancy V.4 Percent Babies With Low Birthweight by Region V.5 Most Important Problem for Respondent During the Week Following Her Most Recent Birth V.6 Most Important Problem for Respondent After Returning Home Following Delivery CHAPTER VI: YOUNG ADULT SEXUAL BEHAVIOR VI.1 Percent of Women Who Ever Had Sexual Intercourse Before Given Age By Age at Interview, 15-24 Year-Old Respondents VI.2 Contraceptive Method Used at First Sexual Intercourse, By Age at First Sex And By Education, 15-24 Year-Old Respondents CHAPTER VII: REPRODUCTIVE HEALTH KNOWLEDGE AND ATTITUDES VII.1 Percent of Respondents Who Think Women Should Be Able to Decide Whether To Have An Abortion For Any Pregnancy, By Education And By Religion VII.2 Opinions About The Reliability of Oral Contraceptives VII.3 Opinions About The Safety Of Oral Contraceptives CHAPTER VIII: WOMEN'S HEALTH VIII.1 Cigarette Smoking Status By Education xxii SUMMARY Introduction From February to July of 1993, a nationally representative household survey of 15 to 44 year-old women, the Czech Republic Reproductive Health Survey (CRRHS), was conducted throughout the Czech Republic. This survey was undertaken in order to explore important issues related to reproduction and women's health in the Czech Republic. The survey was carried out at a time when major reforms in the Czech health care system were underway. It was felt that in this period of change and uncertainty it was important that policymakers and health care providers be aware of the current status of reproductive health and related topics in the population and the use of and need for various health services. The 1993 CRRHS was intended to serve several purposes, among them: updating basic information regarding such topics as family planning use and needs, use of maternal and child health services, and selected women's health issues; determining reproductive health needs for the country as a whole and for population subgroups; and more closely examining some reproductive health topics of special interest, for instance the reasons for high incidence of induced abortion and low prevalence of modern contraceptive use. The 1993 CRRHS was a collaborative effort between several organizations, all of which contributed to its success. Among those organizations were: the United States Agency for International Development, which financed the survey, Factum (a Czech public opinion research firm), the Czech Statistical Office, The World Health Organization Collaborating Center for Perinatal Medicine at the Czech Institute for Maternal and Child Health Care, and the Division of Reproductive Health of the United States Centers for Disease Control and Prevention (CDC). The CRRHS questionnaire covered a wide range of topics related to reproductive health in the Czech Republic. The subject areas included were: Pregnancy and childbearing history; knowledge and use of contraceptive methods; use of maternal and child health services; sexuality, contraception, and pregnancy among young adults; women's health and reproduction issues; knowledge about HIV/AIDS and its transmission; and social, economic, and demographic characteristics. Methodology The 1993 CRRHS was designed to collect information from a representative sample of 15 to 44 year-old women living in households in the Czech Republic. Selection of survey respondents was made using a three-stage cluster design. In the first stage of sampling, 332 census enumeration districts (EDs) were systematically selected from throughout the country. The second stage consisted of selection of a cluster of individual dwelling units within each sampled ED. Finally, in homes in which more than one eligible women 1 lived, one woman was randomly chosen as a respondent. Data collection took place from February until June of 1993 and was done by intensively trained female interviewers from throughout the Czech Republic. Each interviewer was assigned to visit selected households in sample sectors (EDs) easily accessible from her home. Interviews were conducted at respondents' homes and generally lasted between 30 and 60 minutes. At the Czech Statistical Office questionnaires were entered onto computer data files and concurrently edited, using software developed at CDC. A total of 12,747 dwelling units were visited in the 332 sample sectors. Women eligible for interview were identified as residing in 38.2% of these units. Of the 4,870 households identified as containing at least one 15-44 year-old women, interviews were completed in 4,497, for a response rate of 92.3%. Of the women selected, 5.3% refused to be interviewed and 1.6% were never found at home after repeated visits. Respondent Characteristics The residential characteristics, age, and marital status distributions of the sample appears to have been very representative of the 15-44 female population of the Czech Republic. Approximately two-thirds of respondents were married or living in a consensual union at the time of interview, while one-fourth had never been married. By ages 35-39 about one in ten women were currently divorced or separated. The typical age at marriage in the Czech Republic remains quite young, with the median age just 20.7 years. Marriages are highly concentrated between 18 and 25 years of age: only 6% of women were married before age 18, but only 12% were not married by age 25. It is evident that the age at marriage had not changed in recent years, being almost identical for all cohorts of respondents. About four of every ten respondents had received a secondary school diploma. Educational attainment has been increasing, demonstrated by the fact that the percentage who attended only primary school fell from 24% to 7% in a 20-year period, while the percentage who obtained a secondary school diploma rose from 41% to over 50% in the 20-24 and 25-29 year-old cohorts. Almost two-thirds of respondents said they had no religious affiliation and 31% said they were Roman Catholic. The vast majority of respondents lived in homes that contained a bathroom or shower (98%) and a color television (89%). In addition, most homes had an automatic washing machine (75%) and an automobile (64%). Thirty-three percent of homes had a telephone. Childbearing/Abortion Vital statistics on births in the Czech Republic are virtually complete, so that measuring current fertility rates was not a major objective of the survey. However, the data collected in the survey provide much more detailed information on reproduction, as well as information on aspects of childbearing not covered by vital statistics. Each respondent 2 was asked to give a history of all the pregnancies she had ever had, including information about each pregnancy and its outcome. Both childlessness and large families are rare in the Czech Republic. Only 3% of respondents had given birth to four or more children. Among women 35 to 44 years of age, the vast majority of whom have completed their childbearing, there is little variation in family size, with 57% having had two children. Few of the oldest respondents have had very small families (3% with no children and 12% with one child among 40-44 year-olds). For most women/couples childbearing starts soon after marriage (only 28% of women married less than five years were still childless) and stops at relatively early ages as well. The total fertility rate (TFR) for the period leading up to the CRRHS (1990-1992), based on data from the survey was 1.87 births per woman, identical to the rate computed from Czech Republic vital statistics. Childbearing is heavily concentrated in the 20-24 and 25-29 year age groups, with very little childbearing taking place after ages 30-34. Compared to the rest of Europe, Czech women have unusually high fertility before ages 25-29 and unusually low fertility after ages 30-34. There was a clear inverse relationship between education and fertility. The total fertility rate was higher among Catholics (2.1) than among those with no religious affiliation (1.8). Childbearing tends to start early in life, with the median age at first birth being 22.0 years. As with age at marriage, there is no indication that the age at first birth has been increasing. Within five years of the date of first marriage, only 7% of women had not had a live birth. There is a strong preference for a two-child family among women throughout the population. Few women desired to remain childless or to have more than three children. Sixty-nine percent of fecund, married respondents desired to have no more children. Among those with two living children the figure was 86% and among those with at least three children it rose to 94%. Planning Status of Pregnancies After adjustments were made for the underreporting of abortions, we estimated that only 51% of recent pregnancies were planned, 16% were mistimed (i.e., occurred before they were planned), and 28% were unwanted (i.e., in excess of the number wanted), with the remainder unspecified. The proportion of pregnancies that were unwanted rose sharply after ages 30-34 and once women had at least two living children. Most mistimed pregnancies occurred relatively before ages 25-29. After correction for underreporting of abortion it appears that slightly more than half of mistimed pregnancies were aborted and that only about 4% of unwanted pregnancies resulted in a live birth. 3 Knowledge and Use of Contraception Knowledge of pregnancy prevention methods was not an important obstacle to use of contraception. Knowledge of condoms and oral contraceptives was nearly universal and was only slightly lower for the IUD, withdrawal, and natural family planning. Even the least widely known method asked about, vasectomy, was familiar to two-thirds of respondents. Among women currently married or living with a partner, 92 percent had used contraception at some time during their lives. Sixty-nine percent of women who were married or living with a man at the time of interview were currently using some method of family planning. Couples with two or three children were the most likely to be using contraception (75 and 78%, respectively), while only 29% of childless couples were using. Current contraceptive use increased with level of education, at least up to the level of secondary school completion. Women who were not affiliated with a religion were somewhat more likely to be using than women belonging to an organized religion, though there was virtually no difference in contraceptive prevalence between Catholics who regularly attended church and those who did not. The most commonly used contraceptive methods were reported to be withdrawal (22% of married/in union women), condoms (17%), the IUD (15%), and oral contraceptives (8%), which together accounted for over 90% of all contraception. No other methods were currently employed by more than 3% of married women. About 3% of women had been contraceptively sterilized. No respondents reported that their partner had undergone a vasectomy. Reasons for not Using Contraception About two-thirds of women not using contraception at the time of interview gave reasons that related to either a lack of current sexual activity or their pregnancy status (i.e., unable to become pregnant, trying to become pregnant, or currently pregnant). Among the broad assortment of other reasons given, the most common was fear of health effects related to contraception. Religion and inability to obtain methods were rarely cited. Based on these results, it is estimated that as many as one-third of Czech women who were not using contraception were at some risk of unintended pregnancy due to non-use of contraception. Not surprisingly, a lack of sexual activity was the principal reason for not using contraception among women who were not currently married. Among women married or in union, just over half of nonusers reported a reason related to pregnancy status or lack of sexual activity. Reasons such as fear of health effects, difficulty in getting pregnant, and postpartum/breastfeeding were much more common among these women than among those not in union. 4 Need for Family Planning Services The concept of "women in need of family planning services" is useful in determining the extent to which services are reaching those who are at risk of becoming pregnant, but who do not desire to do so. If only women who are sexually active, fecund, not pregnant, not desiring to become pregnant and using no contraceptive method are considered to be in need, then 10% of Czech women of reproductive age are in need of family planning services. If users of withdrawal and natural methods are also included, the figure rises to 31%. Use of Less Effective Methods Even though overall contraceptive prevalence is high in the Czech Republic, there is considerable reliance on the use of methods of relatively low effectiveness, particularly withdrawal. This reliance on methods of low reliability is, no doubt, one of the key factors in bringing about high rates of unintended pregnancy and induced abortion. Of six factors about which users of less reliable methods were asked, only a fear that negative health effects associated with the use of modern methods (75%) was an important consideration in method selection. Religious factors were not a consideration at all for 97% of these women. Many users of these methods were overly confident in their reliability relative to modern methods. Almost half of these respondents thought that their method was at least as effective as highly effective modern methods. Problems with Current Contraceptive Methods Eighty-five percent of contraceptive users said they had had no major problems with their current method. This figure was fairly consistent between methods, ranging from 90% for NFP down to 80% for a combination of condoms and withdrawal. About half of those with concerns reported that reliability/quality was their major one. Consistent with this low level of reported concerns about current methods, 73% of current contraceptors stated that they would prefer to be using their current method rather than switching to another one. Among those desiring to switch from their current method, 40% preferred to use oral contraceptives, followed by the IUD (25%). Surprisingly, the third most preferred method (15% of those preferring another method) was implants, which were not yet available in the Czech Republic at the time of the survey. Contraceptive Sterilization Like most of the other formerly communist states of central and eastern Europe,the Czech Republic has low rates of surgical sterilization, both tubal ligation and, to an even greater extent, vasectomy. Only three percent of married women of childbearing age reported having undergone surgical sterilization, while no women reported their partners to have had a vasectomy, despite the fact that most women complete their desired childbearing 5 many years before becoming unable to bear children. The major exception was the relatively small group of women who have at least four living children, over one-fourth of whom had been sterilized. Only 8% of the respondents who desired no more children reported being interested in undergoing tubal ligation, in addition to the 3% already sterilized. The reason most often given by respondents for not being interested in surgical sterilization was simply that they had not thought about undergoing the procedure. The second most commonly given reason was a fear of health risks associated with the procedure, followed by a fear that the woman/couple may decide to have another child and a fear of surgery. Prenatal Care Heavy physical exertion and emotional stress are thought by some to increase the risk of adverse pregnancy outcomes. Overall, 15% of women described themselves as having done much physical work and 27% said they did a large amount of standing during their jobs. The amount of both physical work and standing decreased sharply as educational level increased. Seventeen percent of women said they were under much stress on their jobs during pregnancy and 32% said they were under moderate stress. The Czech Republic has an impressive record regarding prenatal care coverage. Less than 1% of women with a live birth since the beginning of 1988 received no prenatal care during their most recent pregnancy leading to a live birth. Ninety-four percent of those women began receiving prenatal care during their first trimester, while only 5% waited until after the first trimester. The percentage of women receiving early prenatal care ranged from 97% in South Bohemia down to 90% in North Bohemia and 91% in East Bohemia. Women who were less likely to begin care in the first trimester included those who: were less than 20 years of age or between 35 and 44 years; were not currently married; had only a primary education; were affiliated with a religion other than Catholicism; or had low household income. Not only did women tend to begin prenatal visits early, but 91% reported making at least 10 prenatal visits during pregnancy, with only 1% reporting fewer than six visits. The proportion of women making at least 10 prenatal visits was high across all geographic and socioeconomic categories. Ultrasound Examinations Ninety-two percent of women who received prenatal care reported that they underwent an ultrasound examination during their last pregnancy leading to a live birth. The percentage having an ultrasound exam varied from 98% in South Bohemia and 97% in South Moravia down to 85% in North Moravia and 86% in West Bohemia. The procedure was more commonly done for the youngest (15-24 years) and oldest (40-44) 6 groups of women. However, one-fourth of women who had undergone ultrasound said that no one had explained the reason for doing this procedure and another one-fifth had only had the procedure explained to them slightly. Hospitalization during Pregnancy Hospitalization during pregnancy (other than for labor and delivery) is a common phenomenon in the Czech Republic. Twenty-nine percent of women giving birth since 1988 were hospitalized during some part of their pregnancy, with a mean length of stay of almost one month and a median of two weeks. Although older mothers were no more likely than others to be hospitalized during pregnancy, they tended to be hospitalized for the longest periods of time (mean = 57 days, median = 21 days). The conditions most commonly cited as being responsible for hospitalization during pregnancy were bleeding during the first half of pregnancy (39% of hospitalizations) and early or false labor (33%). Smoking during Pregnancy Sixty-eight percent of respondents with recent live births were not smokers when they became pregnant. An additional 21% reported that they stopped smoking upon learning they were pregnant, with the remaining 11 % continuing to smoke during pregnancy. About one-third of this group smoked at least 10 cigarettes per day. As educational level increased, the likelihood that a woman smoked during pregnancy decreased sharply, from 32% among women with only a primary school education, to 2% for those who attended university. Birthweight The incidence of low birthweight (LBW) (i.e., under 2,500 grams) among recent births was 5.8% among survey respondents. The incidence of LBW was slightly higher among primiparous women (7%) than among multiparous women (5%). Although this difference was not large, the LBW rate was lower among multiparous women in all but a few categories of survey respondents. The highest LBW rates were found in cities of at least 20,000 population, in North Moravia, among the oldest (40-44 year-old) and youngest (15-19 year-old), single women, and poorly educated women. Labor and Delivery The CRRHS questionnaire also inquired into respondents' opinions regarding services received for recent pregnancies and deliveries. Women were asked their impressions about the facility in which they most recently delivered in regard to: distance from home, physical facilities, crowdedness, attentiveness of staff, and competence of staff. Each of the five characteristics was rated as "good" by between one-half and three- quarters of respondents. The characteristic eliciting the most "poor" ratings (20%) was 7 crowdedness. The aspect of care about which respondents were the most satisfied was the competence of the staff. Overall, four-fifths of respondents said that they received adequate information regarding their pregnancy. Multiparous women were somewhat more satisfied than primiparous women. The level of satisfaction with information provided about delivery was 68%, lower than for information about pregnancy. Among multiparae 72% were satisfied, compared with 61% of primiparae. Problems in the Post Partum Period Forty percent of respondents said they had no major problems during the first week following delivery. The problems most commonly mentioned related to the health and care of the baby (18%), the woman's own health (17%), and breastfeeding (11 %). Care of the child was mentioned most commonly by the youngest and oldest respondents and by women who had never been married. Breastfeeding concerns stood out as a problem among university educated and primiparous women. Fifty-eight percent of respondents said they had no major problems after returning home from the hospital. The problems mentioned most frequently were her own health (10%), health of the child (8%), care of her child/children (7%), and home environment (5%). Health of the child was a major concern among the youngest women and single women. Care of the child was most commonly mentioned by university educated and primiparous women, but rarely by multiparous women. Breastfeeding Ninety-one percent of children born to respondents since the beginning of 1988 were breastfed for at least some period of time. The proportion breastfed was lowest for infants with mothers ages 15-19 (84%) or ages 40-44 (71 %). Despite the fact that relatively few infants were never breastfed, the mean duration of breastfeeding was short: 3.7 months for all children and 4.2 months for children who were reportedly breastfed. Young Adult Reproductive Health The survey estimate of the median age at first intercourse was 17.5 years. It appears that the age at which females begin having sexual relations has been decreasing, since the median age was 0.5 years less for those 15-19 years of age than for those five years older. Sexual intercourse before age 15 is still fairly rare for girls. By about age 21, only a small fraction of women were not yet sexually experienced. The proportions reporting that they had had sexual intercourse were 36% of 15-17 year-olds, 82% of 18-19 year- olds, and 98% of 20-24 year-olds. Bohemian women tend to become sexually active slightly earlier than Moravian women (39% experienced, as opposed to 31% among 15- 19 year-olds). Likewise, women espousing no religion start sexual relations earlier than 8 Catholics (37% compared with 32%). Clearly premarital sexual intercourse has become the norm in the Czech Republic: Over 99% of sexually experienced women first had intercourse before they were married. Forty-two percent of young adult respondents reportedly used no form of contraception the first time they had sexual intercourse. Among those who did use contraception, over 90% used either withdrawal or condoms. Of those females who did not use contraception at first intercourse, 44% said the reason was that they did not expect to have sex, while 27% said they did not think it was possible for them to become pregnant. About one-half of 15-24 year-old respondents reportedly had ever been pregnant at the time of interview and about half of those said they were not married at the time they became pregnant. (Because of abortion underreporting, however, the actual percentages may be higher than indicated in the survey.) Reproductive Health Knowledge and Attitudes The rate of induced abortions in the Czech Republic is quite high, with official statistics for 1992 showing 48 abortions per 1000 15-44 year-old women and 78 abortions for every 100 live births. Abortion laws are permissive, although minor restrictions have been added in recent years and the cost of having an abortion performed has increased substantially. An overwhelming majority of childbearing age women (85%) felt that women/couples should have the right to decide whether to have a pregnancy terminated by means of induced abortion for any reason they choose. Every segment of the population examined was similarly opposed to legal restrictions on a woman's obtaining an abortion. Even among Catholic women who attend mass regularly, seven of every ten felt there should be no limitations on access to abortion. Even among the 14% of respondents who thought that there should be some restrictions on access to abortion, an overwhelming majority felt that abortion was justified under at least some circumstances, particularly if a pregnancy endangered a woman's life or if there was risk of a fetal defect. Only about half of respondents said that a women who took oral contraceptives correctly could be completely or almost sure that she would not become pregnant and one of every five women indicated that the reliability of oral contraceptives was quite low. About one-fifth of women felt that oral contraceptives were unsafe, while a slightly smaller percentage said they did not know if they were safe. Fifty-three percent of women were aware that oral contraceptives make menstrual periods more regular, while 42% felt that oral contraceptives cause weight gain. Sizable minorities of respondents agreed with the statements that oral contraceptives: increase 9 the risk of getting cancer (25%); are bad for blood circulation (21%); can cause infertility (16%); and cause nervousness (13%). About half of respondents for each of these four statements said they did not know whether they were true. Respondents were asked whether they agreed or disagreed with selected statements regarding women's roles and reproduction. Few women agreed with the statements that "Child care is women's work" and "A woman should be a virgin when she marries", while most agreed that it is all right for women not to have children if they so desire. These results indicate that most Czech women do not feel that women should be restricted to traditional roles. Women's Health It is recommended that women of childbearing age receive complete gynecologic examinations on a yearly basis; 60% of respondents reported that they go for gynecologic exams at least that often. At the other extreme, 15% of women said they never go for such exams. The group least likely to be examined was 15-19 year-olds, among whom only 30% had yearly exams and 59% never had them. Two-thirds of women who did not receive yearly exams said the reason for this was that they did not have any gynecologic problems. It has been well established that cigarette smoking is an important risk factor for cancer, respiratory diseases, and cardiovascular disease, among other chronic conditions. Thirty percent of CRRHS respondents reported that they currently smoked. Another 12% had smoked in the past, but no longer did. Smoking prevalence was highest in North Bohemia and Prague and lowest in Moravia and adjacent East Bohemia. Rates also tended to be higher in large cities than elsewhere. Only 19% of smokers were light smokers, that is, they typically smoked fewer than five cigarettes per day. The largest proportion of smokers, 44%, smoked 10 to 19 cigarettes per day, while 16% smoked at least one pack per day. Relatively few Czech women reported chronically consuming large amounts of alcoholic beverages. Only 3% of respondents said that they consume an average of more than seven alcoholic drinks per week. Almost eight of every ten women consumed either fewer than three or three to seven drinks per week, while one-fifth said they did not drink at all. Based on reported heights and weights, 15% of respondents met the criterion for being substantially overweight. This percentage was lowest in Prague (10%) and tended to be highest in places with populations under 5,000 people (21%). Knowledge of Transmission of HIV/AIDS Even though, according to official statistics, the incidence of HIV infection was not yet 10 very high in the Czech Republic at the time of the CRRHS, a threat of increased spread of the infection existed. This was especially true in light of the increased numbers of people entering the Czech Republic from other countries and the newfound freedom of Czechs to travel outside their own country following the fall of the communist government. The CRRHS included a series of questions intended to measure the knowledge of Czech women regarding HIV/AIDS in general and the means by which HIV is transmitted to individuals. All but five respondents (99.9%) reported that the had heard of AIDS. In general, there appeared to be a high level of awareness of those means by which HIV is known to be transmissible-sharing needles (98%), male homosexual relations (96%), and heterosexual relations (94%). Receiving a transfusion, which in many settings can lead to transmission, was felt to be a cause of AIDS by 89% of women. Almost half of women thought a person could be infected by giving blood or by going to a physician or dentist, behaviors that cannot transmit infection except under unusual circumstances. Among those methods asked about by which the virus is known not to be transmitted, the proportion who felt that HIV could be spread ranged from 28% for kissing on the mouth down to 3% for shaking hands. Only about three-fourths of respondents felt that condoms provided excellent or good protection against transmission of HIV. Eighty-three percent of women felt they had no risk of becoming infected with the AIDS virus, 3% felt they had a low risk, and 5% felt they had a high risk. There was very little variation in these percentages across the population. 11 I. INTRODUCTION/SURVEY METHODOLOGY In 1993, a national survey of reproductive health issues was conducted in the Czech Republic. The Czech Republic, with a population of 10.4 million people, lies in central Europe, covering an area of 78,864 square kilometers (30,590 square miles). Since 1918, the Czech Republic had constituted the western three-fifths of Czechoslovakia prior to the January 1993 breakup of that country. The country consists of two historical areas, Bohemia in the west, which is divided into six regions, and Moravia and Silesia in the east, divided into two regions. At the time the survey was carried out, the crude birth rate (births per 1,000 population per year) was estimated to be about 12 per 1,000 and the crude death rate was about 11.1 per 1,000, with the annual rate of natural increase being about 0.1 percent (Population Reference Bureau 1994). According to the 1991 Census, 75% of the Czech population lived in places classified as urban, with 22% of people living in cities with at least 100,000 people (Czechoslovakia Federal Statistical Office 1991). Average life expectancy was estimated to be 77 years among females and 69 years among males (National Public Health and Hospital Institute 1994). Ethnically, the Czech Republic is highly homogeneous, with the overwhelming majority of residents (about 95%) identifying themselves as Czech (or Bohemian or Moravian). The largest numbers of non-Czech residents are Slovak, Romany (Gypsy), Polish, and Silesian. The Czech language is the primary language for all but a very small percentage of the entire population. Survey Background The 1993 Czech Republic Reproductive Health Survey (CRRHS) was a nationally representative household survey of women 15 to 44 years of age, undertaken in order to explore important issues related to reproduction and women's health in that country. This survey was carried out at a time when substantial reforms in the Czech health care system were taking place or were being considered (Albert 1992; Massaro et al 1994; NPHHI 1994; Raffel 1992). The reforms taking place have largely grown out of the fall of communism and the resultant changeover to a free market economy, the rise of democracy, and the breakup of the Czechoslovak Federation. Among the changes underway at the time of the survey were: Reforming the administrative structure of the health care system from one in which most responsibility for health care delivery resided at the regional level to one in which districts, municipalities, and the national Ministry of Health take over those responsibilities; privatization of the health sector, including hospitals, polyclinics, physician services, and pharmacies; and, reforming health care financing by introducing a system of health insurance, rather than having health care funding completely centralized and financed from general tax revenues. In this period of change and uncertainty it is important that policymakers and health care providers be aware of the current status of reproductive health 12 throughout the population and the use of and need for various services related to family planning and maternal and child health. The CRRHS was intended to serve several purposes. The last large, national survey covering a wide array of demographic and reproductive health topics was the 1977 Czechoslovakia Fertility Survey (World Fertility Survey 1978). Because no such surveys had been conducted in recent years on family planning and reproductive health in Czechoslovakia or the Czech Republic, this survey was the first opportunity in many years to update basic measures, such as contraceptive prevalence, unmet need for contraception, use of maternal and child health services, and many others. These measures constitute important information in determining a population's needs and problems. In recent years, at least two useful surveys have been carried out, but both were relatively limited in regard to both content or sample size (Kraus 1987; Uzel, Ketting, et al. 1992). The size and scope of the 1993 CRRHS allows highly detailed analysis with regard to many reproductive health questions for subgroups of the Czech population. There are several issues in the area of reproductive health in the Czech Republic that were known to merit close examination prior to carrying out the 1993 CRRHS. Official statistics show that the rate of induced abortion and the ratio of abortions to live births has remained very high (although they appear to have declined recently). Reducing the number of abortions would be in the best interest of public health in the Czech Republic, regardless of one's views regarding the legality and morality of abortion. It appears that modern, highly reliable contraceptive methods are not as widely used as they are in most other developed countries. The failure to use such methods contributes to high rates of unintended pregnancy. Furthermore, pregnancy and unprotected intercourse among Czech women under 18 years of age appear to be quite widespread. In addition, relatively little data exist on the extent of certain behaviors that affect the health of women and their infants, such as smoking, alcohol consumption, and the prevalence of being overweight. The CRRHS was designed to provide information that would contribute to strategies for addressing these issues in the Czech Republic. Besides information about health status and practices, the 1993 CRRHS measured attitudes and opinions about the quality and types of reproductive health services offered, restrictions on the availability of induced abortion, and problems associated with the use of modern contraceptives. Also, as AIDS emerges as an important public health problem, it is important to find out how well informed women are about the means of transmission and prevention of this disease. Organizational Structure The 1993 Czech Republic Reproductive Health Survey was a collaborative effort between several organizations and many individuals. It would not have been successful without the contributions of each and the cooperation that existed between them. Funding for the 1993 CRRHS was provided by the United States Agency for International Development, through a 13 contract with the World Health Organization's European Office. Fieldwork was conducted by Factum, a Czech public opinion research firm, which coordinated the recruitment and training of interviewers and all aspects of data collection. The Czech Statistical Office (CSO) was responsible for preparing the sampling frame and carrying out data entry and editing, as well as providing the physical facilities for the survey. The World Health Organization (WHO) Collaborating Center for Perinatal Medicine at the Czech Institute for Maternal and Child Health Care assisted with the design of the questionnaire and data analysis and was responsible for financial accounting. The Division of Reproductive Health of the United States Centers for Disease Control and Prevention (CDC) provided assistance in survey design, questionnaire development and survey implementation and played the leading role in analysis of the data and report preparation. CDC, CSO, and Factum in developing the survey methodology. All of the above-mentioned organizations collaborated on the development of the questionnaire, data analysis, and report preparation. In addition, many other individuals provided valuable assistance or information that was important in the development and implementation of the survey. Questionnaire Content The CRRHS questionnaire covered a wide range of topics in the area of reproductive health and related areas. The specific subject areas included were: ► Pregnancy and childbearing history ► Knowledge, past and present use of, and need for contraceptive methods ► Use of maternal and child health services ► Sexuality, contraception, and pregnancy among young adults (15-24 years) ► Women's health issues ► Knowledge and attitudes about selected issues in reproduction ► Knowledge about HIV/AIDS and its transmission ► Social, economic, and demographic characteristics An English translation of the CRRHS questionnaire is included as Appendix A of this report. Most of the results in this report are presented according to geographic, social, economic, and demographic characteristics, making it possible to identify the population segments where health needs or problems tend to be most acute. Sample Selection The 993 CRRHS was designed to collect information from a nationally representative sample of women of reproductive age from throughout the Czech Republic. The universe from which women were selected consisted of all females between the ages of 15 and 44 years living in households in the Czech Republic at the time that the survey was carried out. Although some pregnancy and childbearing takes place outside the ages 15 to 44, because of 14 the relative rarity of these events at those ages, it was decided that it would be most efficient to limit the sample to women between 15 and 44 years of age. Selection of survey respondents was made using a three-stage cluster sampling design. First, 166 pairs of basic census enumeration districts (ED) (332 districts in all) were systematically selected from throughout the country, with the probability of selection proportional to the population of each census enumeration district. These 332 ED constituted the primary sampling units (PSU) for the survey. The sample included ED in all but one of the Czech Republics 85 districts. The Czech Statistical Office then made listings available of all known dwelling units in each of the selected ED. These listings were taken from the 1991 Population and Housing Census. Because the selection of PSUs was done proportional to population size and no strata were oversampled, the sample was geographically self- weighting. In the second stage of selection, individual dwelling units were sampled from each ED chosen in the first stage. Because of slightly different mean numbers of 15 to 44 year-old women per household according to size of community, the number of dwelling units selected in an ED depended on the population of the community in which the ED was located, as follows: Community Selected Population Dwelling Units 1-4,999 43 5,000-19,999 37 20,000+ 39 One dwelling unit was randomly chosen from the each PSU. That unit and the 42, 36, or 38 units (depending on the community population) listed next constituted the sample of housing units to be visited. No substitution was made for dwellings that were unoccupied or where nobody was at home. By varying the number of units selected according to the average number of women per household we were able to hold fairly constant the average numbers of women living in selected ED across population size categories. If the selected ED had fewer households than were needed to constitute a sample sector, all dwelling units were sampled and another ED (the one with the next highest number, which was usually geographically contiguous) was added to the sample. The third and final stage of sampling consisted of the selection of individual respondents. In households in which more than one woman between the ages of 15 and 44 lived, the household respondent was asked for a listing of all such females. One of those women was randomly selected by the interviewer to be the survey respondent. During analysis each record was weighted by the number of women of childbearing age in the household, to compensate for the fact that only one woman per household was selected with probability inverse to the number of women in the household. 15 Data Collection Data collection for the CRRHS was done by about 150 female interviewers from throughout the Czech Republic. Each interviewer received intensive training in interviewing techniques, field procedures, and proper administration of the CRRHS questionnaire. Each interviewer attended one of three training courses held immediately before the beginning of field work, two in Prague and one in Brno in January and February of 1993. These sessions included practice interviews with community residents to ensure that interviewers were able to administer the questionnaire competently. Data collection lasted from February until June of 1993. Each interviewer was assigned to visit selected households in from one to three sample sectors easily accessible from her home. Interviews were conducted at respondents' homes and generally lasted between 30 and 60 minutes. Completed questionnaires were sent by the interviewer to her supervisor, who reviewed each questionnaire and, if it was satisfactorily completed, forward it to the Czech Statistical Office. Data Entry/Editing At the Czech Statistical Office questionnaires were reviewed once more by coordinators and sent for data entry. Questionnaire data was entered onto computers by three clerks, using SURVEY, a data entry/editing package developed at CDC. The SURVEY package is used to edit data as they are entered, by identifying data items that are outside of their allowable range or inconsistent with other information on the questionnaire. Response Rates A total of 12,747 dwelling units were visited in the 332 sample sectors. Women eligible for interview were identified as residing in 38.2% of these units (Table I.1). In 52.2% of the households visited there were no 15-44 year-old women resident. Nobody was home at 4.0% of units and 3.0% of units were uninhabited. Residents refused to be interviewed at 2.7% of households. As the size of community increased, the percent of refusals increased slightly and the percent of households with no eligible females decreased. Of me 4,870 households identified as containing at least one 15-44 year-old female, interviews were completed in 4,497, for a completion rate of 92.3%. Of those women selected, 5.3% refused to be interviewed and 1.6% were not found at home, even after repeated visits. The completion rate fell slightly as community size grew, from 93.8% in towns under 5,000 population to 91.3% for cities with at least 20,000 people. In regard to residential characteristics, the sample appears to have been highly representative of the 15-44 year-old population of the Czech Republic. Of the Czech Republic's nine regions, only in Prague was the difference between the 1991 Census and CRRHS proportion of the female 15-44 year-old population as much as two percentage points (Table I.2). 16 Likewise, the census and survey distributions of size of place of residence were very similar. 17 18 19 II. RESPONDENT CHARACTERISTICS Not only did the residential distribution of survey respondents closely resemble the distribution for the nation as a whole as reported in the census, the age and marital status distributions of women were also similar in the 1991 Census and the CRRHS (Table II.1). The proportion of women within each five-year age group was within two percentage points in the two sources, indicating that the CRRHS was representative of the national population with regard to age. Marital status distributions were also similar, although survey respondents were slightly more likely to be currently married and less likely to be never married/in union than were women enumerated in the 1991 Census. Distributions of marital status, educational attainment, and religious affiliation at the time of interview for the CRRHS respondents are displayed in Table II.2. Approximately two- thirds of respondents were married or living in a consensual union (i.e., living with a man, but not legally married) at the time, while one-fourth had never been married. The proportion of women married or in union stops rising after ages 25-29 at about 85%. By ages 30-34 almost one-tenth women were currently divorced or separated. About four of every ten respondents had received a secondary school diploma. About one-fifth of secondary school graduates had attended university. The CRRHS results indicate that educational attainment has been increasing. The percentage who attended only primary school fell from 24% to 7% in a 20-year period, while the percentage who obtained a secondary school diploma rose from 41 % to over 50% in the 20-24 and 25- 29 year-old cohorts (Figure II.1). (We have ignored 15-19 year-olds in this part of the analysis data because many respondents of that age were still in school at the time of interview.) Almost two-thirds of respondents said they had no religious affiliation. Thirty-one percent of respondents said they were Catholic. The percentage saying they had no religion decreased steadily as age increased (Figure II.2). Among those under age 30 about seven of every ten women reported they belonged to no religion. Table II.3 shows that the largest group of women (40%) lived in households where the total monthly income was between 3,000 and 7,000 Crowns (about US$100-250). Relatively few respondent households had a monthly income below 3,000 Crowns or above 15,000 Crowns. Sixty-one percent of respondents said they were currently working, while another 8% were reportedly on maternity leave. Among those who were employed, two-thirds worked between 40 and 44 hours per week. The CRRHS questionnaire included questions on whether respondents' homes contained selected possessions, listed in the top panel of Table II.4 and in Figure II.3. The vast majority of homes contained a bathroom or shower (98%) and a color television (89%). In addition, most homes had an automatic washing machine (75%) and an automobile 20 21 22 23 (64%). Telephones were present in 33% of respondent households. Table II.5 reveals that, in spite of the recency of the conversion to a free market economy, 43% of respondents lived in residences owned by her or her family and only one-third still lived in residences rented from the state. Ten percent of respondents lived in residences which they shared with another family. Most of the households in which respondents lived contained three or four people. Table II.6, which presents distributions of several characteristics, controlling for respondent education, excludes women under 20 years of age, since many of them had not yet finished their education. Not surprisingly, there was a strong correlation between the education of respondents and their partners (Table II.6), but, it was not unusual for women to be married to men with slightly less education than themselves. There was a distinct association between education and household income, but even among those who attended university there were relatively few women in the highest income category (11%). Since income increased with educational attainment, it is not surprising that the number of selected possessions (color television, automatic washer, automobile, VCR, telephone, personal computer) rose with education as well. The proportion of respondents with five or six of these items increased from 6% for women with primary education to 23% for those with any university education. It is clear from the results shown in Table II.7 and in Figure II.4 that age at marriage in the Czech Republic is typically quite young, with the median age at marriage (based on life table estimates) just 20.7 years. (Though not strictly comparable, the mean age at first marriage for Europe as a whole is 25 years and for Eastern Europe is 22 years (Population Reference Bureau, 1994b)). It also appears that marriages are highly concentrated between 18 and 25 years of age: only 6% of women married before 18, but only 12% were not married by age 25. It also is evident that the age at marriage has not changed in recent years, being almost identical for 15-24, 25-34, and 35-44 year-old respondents. Age at marriage was similar in Bohemia and Moravia and varied little according to the size of the place of residence. Median age at marriage increased with educational attainment, but even among those women who attended university, it was only 23.5 years. Table II.8 shows the percentages of first marriages that were still intact at the time of interview, controlling for the number of years that had passed since the date of marriage. Overall, 79% of marriages were still intact, ranging from 91% of those that began less than five years before interview to 70% of those that began at least 20 years before interview. Several variables appear to be related to the survival of marriages, even when duration is held constant. Marriages in Bohemia were less likely to survive than those in Moravia at all durations. Marriage survival was inversely correlated with size of place, with only 73% of marriages of women living in large cities still intact. Women who attended only primary school were less likely to have intact first marriages, regardless of years since marriage. Women affiliated with religions other than Roman Catholicism 24 25 were the most likely to experience marital dissolution. Catholics who regularly attended religious services were the most likely to be in intact first marriages. Women who married young were much more likely than other women to no longer be in their first marriage, especially if the marriage took place before age 18. 26 27 28 29 30 31 32 33 34 III. CHILDBEARING/ABORTION One of the major reasons for conducting the 1993 CRRHS was to learn more about trends, differentials, and patterns of childbearing in the Czech Republic. Vital statistics on births in the Czech Republic are virtually complete, so that measuring current fertility rates was not a primary objective of the survey, unlike similar surveys carried out in developing countries. However, the data collected in the survey provide much more detailed information on reproduction, as well as information on various aspects of childbearing that are not recorded by the vital statistics system. Each respondent was asked to give a history of all the pregnancies she had ever had, including information on the duration, and the outcome of each pregnancy, as well as the sex and survival of each child born alive. Respondents were asked about the intendedness of each pregnancy ending after 1987 and breastfeeding of children born after 1987. Finally, women were asked about the numbers of children they would like to have and the number they planned to have when they first married. (The survey results on health and medical aspects respondents' pregnancies and deliveries, as well as maternal health are presented in Chapter 5, "Pregnancy, Delivery, and Infant Health"). Children Ever Born Table III.1 presents percentage distributions of the number of live births to respondents according to age and years since the start of first union at the time of interview. Only 3% of respondents had given birth to four or more children. The largest number of live births for any respondent was seven, reported by only three (0.1%) women. Among women 35-39 years and 40-44 years, the vast majority of whom had completed their childbearing, there was strikingly little variation in family size. Fifty-seven percent have had two children, by far the most common number of children for these cohorts of women. Few of the oldest respondents have had very small families (3% with no children and 12% with one child among 40-44 year-olds) and, likewise, few have had large families (5% with four or more children). Similar figures are seen for those women who were first married (or in union) at least 10 years before interview. Among those women never in union, 5% reported having any live births. It is evident, as will be demonstrated in later tables, that childbearing tends to start soon after marriage (only 28% of women married less than five years were still childless) and stop at relatively early ages as well. Table III.2 presents mean numbers of children ever born (parity) according to selected characteristics, controlling for respondents' ages at the time of interview. The fact that the mean parity for women at ages 35-39 and 40-44, 2.1 and 2.2, respectively, are higher than the total fertility rate at the time of the survey (1.9, as will be shown below) indicates that fertility rates have fallen somewhat in recent years. Differences in mean numbers of live births tended to be small among most population 35 subgroups examined. There was virtually no difference between Bohemia and Moravia, while there was a very slight inverse correlation between size of place and mean parity. A stronger inverse correlation was noted between educational attainment and parity, especially at younger ages. However, unlike in most other developed countries, where an inverse correlation exists between income and parity, no such relationship was observed in the Czech Republic. This may be the result of a situation which is only now starting to change, whereby salaries and social status have not been highly associated. The mean parity of Roman Catholics tended to be slightly higher than for women with no religious affiliation. Current Fertility The total fertility rate (TFR) for the three-year period preceding the CRRHS (1990-1992), based on data from the survey was 1.87 births per woman, identical to the rate computed from Czech Republic vital statistics (Table III.3). This confirms that, as in all but a few European countries, fertility rates have fallen below the replacement level of 2.1 births per woman (Althaus 1992). It also lends great confidence in the quality of the live birth data reported by women in the CRRHS. Figure III.1 shows TFRs for many countries in Europe in about 1991. The rate for the Czech Republic, although low by world standards, is not atypical for Europe. For the former Czechoslovakia, the TFR rose between the late 1960s and the mid-1970s from about 2.0 children per woman to a level of 2.5 children per woman. Fertility then declined steadily, but very gradually, from the middle of the 1970s until the time of the survey (United Nations 1986-1990). (For a description of the substantial decline in Czech fertility over the past two centuries, see Fialova et al. (1990)). Throughout the former Soviet bloc fertility fell untill the mid 1960s, after which trends diverged, depending predominantly on government policies and abortion restrictions (Festy 1991). Table III.3 also shows that age-specific fertility rates computed from survey data closely match those from Czech vital statistics. Table III.3 reveals that childbearing in the Czech Republic is very heavily concentrated in the 20-24 and 25-29 year age groups, with very little childbearing taking place after ages 30-34. Figures III.2 and III.3 demonstrate the extent to which childbearing starts and ends early in the Czech Republic. These figures portrat age-specific fertility rates for almost all European countries (excluding former Soviet republics) for 1990, the midpoint of the time period for which fertility was measured in the CRRHS data. It is readily apparent that the Czech Republic has unusually high fertility at ages 20-24 and unusually low fertility at ages 30-34. This is a pattern of childbearing exhibited by most eastern European populations in recent decades. Despite the social and economic changes experienced recently and the Czech Republic's nearness to and exposure to western Europe, there was still no indication of any changes in this pattern at the time of the survey. Table III.4 presents TFRs for various population subgroups for the period 1990-1992. Fertility was somewhat lower in larger cities (over 20,000 population) than in smaller 36 37 38 39 places, 1.7 and 2.0 children per woman, respectively. There was a clearly inverse relationship between education and fertility. Fertility was especially low among women who had attended a university, 1.5 births per woman. The fertility rate was higher among Catholics (2.1) than among those with no religious affiliation (1.8). Timing of First Births It has already been noted that marriage tends to occur early in the Czech Republic and that, by European standards, rates of childbearing at young ages are very high. Table III.5 reveals that, even though the percentage of women with births before their eighteenth birthday was quite low (3%), the percentage who have given birth before their twenty-fifth birthday was extremely high (79%). The median age at first birth, based on life table estimates, was 22.0 years, virtually the same as the mean age at first birth reported in the 1977 Czechoslovak Fertility Survey (World Fertility Survey, 1978). The timing of first births varied little according to region or size of place of residence. As with age at marriage, there was no indication that the age at first birth had been increasing, unlike most other developed countries. In fact, the median age at first birth was lower and the percentages giving birth before selected ages were slightly higher for the younger cohorts than for the oldest cohort. However, the median age at first birth increased with education and was particularly high among women who attended a university (25.4 years). By age 25, just under half of these women had given birth, a far lower percentage than for other women. Table III.6 focuses on the timing of first births relative to the beginning of marriage or cohabitation. Only 4% of respondents reported giving birth before being in union, but by the time they had been in union for just one year, 54% reportedly had borne a child. Within five years of the date of first union, only 7% of women had not had a live birth. The median duration at first birth was only 0.9 years (about 11 months). Clearly, the societal norm in the Czech Republic has remained having a child within a short time of marrying. There was no sign that couples are waiting longer to have their first child; the median duration at first birth is similar for all cohorts. The well educated waited only slightly longer to have a child than other women. Thus, the fact that well educated women tend to have their first birth later in life than other women is primarily a function of the fact that they tend to marry later, and not that they delay childbearing once they are married. Desired Number of Children All respondents were asked about the number of children they currently desired to have, while ever-married respondents were also asked the number they had intended when they first got married. Table III.7 shows that women had a very strong preference for a two-child family at the time of marriage. Two-thirds of all women ever in union and three fourths of those who had formed an idea of how many children they wanted, said they had desired two children. Very few women said that they had wanted to remain 40 childless (1%) or have four or more children (3%). There was an overwhelming preference for two children in every subgroup of the population examined. There was relatively little variation in desired family size at marriage according to place of residence, age, years since marriage, or education. Religious Catholics (i.e., those attending mass at least monthly) were more likely to express a desire for a larger family, with about one-third saying they wanted at least three children. Table III.8, which consists of a cross-tabulation of the number of children planned at the time of marriage by the number currently planned, shows that the preference for the two-child family remains strong after marriage and that there is much changing of preferences and/or failure to achieve desired family size. Most women who revised their preferences reported they now wanted to have two children. None of the women who said they had wanted to remain childless at marriage still wished to do so when interviewed and almost half wanted to have two children. Forty percent of those originally wanting one child said they now desire to have two. One-third of those originally wanting three children wanted two at the time of interview. According to Table III.9, of all fecund respondents who were currently in union, 69% desired to have no more children. Among those with two living children the figure was 86% and among those with at least three children it rose to 94%. Somewhat surprisingly, except among childless women and those with at least three living children, the proportion of women wanting no more children declined as education increased. This relationship did not exist between desire for more children and household income, however. Catholics who attended church regularly were less likely than others to want to have no more children. Women using modern contraceptive methods were the most likely to want no more children. However, large percentages of women using no contraception also wanted no more children, an indication of the existence of unmet need for family planning. The figures in Table III.10 and Figure III.4 reconfirm the popularity of the two-child family in the Czech Republic. Sixty-seven percent of women with no living children would have liked to have two children, 49% of those with one child wanted one more, and 86% of those with two children wanted no more. There appears to be considerable acceptance of the one-child family, since 30% of women with one child wanted no more, even though few childless women said they only wanted one. There is almost no desire to have large families, with very few women indicating they want to have three or more children. The majority of this small group consisted of women with no children yet, many of whom will, no doubt, reduce their expectations as they get older. Planning Status of Pregnancies For every pregnancy ending since January 1988, respondents were asked, first, whether they intended to get pregnant and, if the pregnancy was unintended, whether they had intended to have no more children or had intended to wait longer to have them. If the 41 42 respondent wanted to have no more children, the pregnancy was termed "unwanted". If she wanted to wait longer to become pregnant, it was termed "mistimed". If she reported that she did want to become pregnant when she did, the pregnancy was considered "planned". (David et al. (1988) discuss some of the disadvantages encountered for many Czech children who were unplanned in their research on births to women who were denied abortions.) Table III.11 presents percentage distributions of planning status for all reported pregnancies according to selected characteristics. The figures presented in Table III.11, however, almost certainly represent a substantial underestimate of unplanned, and particularly, unwanted pregnancies in the Czech Republic. As is discussed later in this chapter, we estimated that about half of induced abortions (and the pregnancies leading to them) were not reported by respondents. We can safely assume that all but a small proportion of these pregnancies were unplanned and that a large majority of them were unwanted. After adjustments were made for abortion underreporting we estimated that only about 51% of recent pregnancies were planned, 16% were mistimed, and 28% were unwanted, with the remainder of unspecified status. Despite the underreporting of unplanned pregnancies, the results in Table III.11 are useful for examining relative levels of unintendedness among various population subgroups. As size of place increased, so did the percentage of pregnancies that were reportedly unwanted. The proportion of pregnancies that were unwanted rose sharply from ages 25-29 and once women had at least two living children. Most mistimed pregnancies occurred relatively early: before ages 25-29, i.e., before many women/couples have attained their desired family size. The percent planned was lowest and the percent unwanted was highest among women with only a primary school education. There was relatively little difference in planning status according to religion, except that Catholics who regularly attended services reported somewhat fewer mistimed and unwanted pregnancies than other women did. Table III.12 shows distributions of pregnancy outcomes according to the reported planning status of pregnancies. Again because of underreported induced abortion, the figures in this table relating to the three categories of unplanned pregnancy (mistimed, unwanted, and unspecified) are not completely reliable. Of planned pregnancies, 82% resulted in a live birth. In addition, most of the 6% of pregnancies that were current would also end with a live birth. After correction for underreporting, it appears that slightly more than half of mistimed pregnancies were aborted. Unwanted births are relatively rare events in the Czech Republic. After adjusting for unreported abortions, we estimated that only about 4% of unwanted pregnancies resulted in a live birth. Induced Abortions Much of central and eastern Europe in recent decades has been characterized by very high incidence of induced abortion (Blayo 1991; David 1992; Ketting 1992). Abortion 43 has been widely used in most of these countries as a primary or backup method of family planning. Table III.13 consists of a list of recent induced abortion indicators, based on official statistics, for most of the countries in that part of the world, taken from Blayo (1993). According to these statistics, except for Albania, all other countries recorded at least 38 percent of known pregnancies ending in induced abortion. The rates for the Czech Republic (1.56 lifetime abortions per woman and 46% of pregnancies ending in abortion, as well as 42 abortions per 1,000 15-44 year-old women and 84 abortions per 100 live births in 1991) were lower than, in many of the former Soviet bloc countries of eastern Europe, but were likewise much higher than the rates found in the rest of Europe. Since Czech medical statistics are thought to provide virtually complete counts of induced abortion, the CRRHS was not intended as a tool to measure the incidence of abortion. The completeness of Czech abortion statistics allowed us to estimate the completeness of abortion reporting in the CRRHS and to adjust the survey estimates. As has been found in most surveys that have addressed the subject, it was apparent that the number of induced abortions was substantially underreported in the 1993 CRRHS. Based on comparisons with Czech medical statistics, it was estimated that CRRHS respondents only reported between 45 and 50 percent of the abortions they underwent. Finally, women who reported having any abortions since the beginning of 1988 were asked to give the most important reason that they decided to have an abortion, rather than continue with the pregnancy. Table III.14 shows that over one-third of abortions occurred primarily because women did not want to have any more children. Fifteen percent were because women wanted to wait longer to have another child. Fourteen percent were said to be the result of the inability to afford another child. Less commonly stated reasons were: childbearing was risky for the woman (10%), her partner wanted her to have the pregnancy terminated (5%), her relationship had ended (3%), and diagnosis or fear of a fetal defect (3%). It is unknown whether these percentages would change significantly if survey respondents had reported all induced abortions. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 IV. FAMILY PLANNING One of the primary objectives of the 1994 CRRHS was to learn more about the use of both modern and traditional methods of preventing pregnancy. Many of the countries of central and eastern Europe are known to have relatively low rates of childbearing, despite modest levels of use of modern contraception, largely through widespread reliance on induced abortion (Blayo 1991; David 1992). The 1993 CRRHS was designed to provide detailed information on women's knowledge and use of contraceptive methods, factors involved in method selection, reasons for nonuse of modern methods by women/couples wishing to avoid pregnancy, unmet need for family planning services, interest in surgical sterilization, and related topics. Knowledge of Methods for Preventing Pregnancy Each respondent was asked whether she was familiar with each of nine contraceptive methods. Women were not asked about methods generally unavailable in the Czech Republic, such as Norplant and injectable contraceptives. It is clear that knowledge of pregnancy prevention methods is not an important obstacle to use of contraception. As shown in Table IV.1, among women in union, reported knowledge of every method asked about was widespread. Knowledge was nearly universal for condoms and oral contraceptives and was only slightly lower for the IUD, withdrawal, and natural family planning (variously known as the fertile days method, periodic abstinence, or the rhythm method). Even the least well known method, vasectomy, was familiar to about two- thirds of respondents. For each of the nine methods, knowledge tended to increase with respondents' level of education. Among women who had attended university, knowledge was over 90 percent for every method. There were no substantial differences in knowledge of contraception according to other socioeconomic, demographic, and residential characteristics examined, except that respondents under the age of 20 were considerably less likely than others to know about each of the nine methods. Ever Use of Contraception Among women currently married or living with a partner, 92 percent had used contraception at some time during their lives (Table IV.2). When the analysis is limited to modern methods (i.e., withdrawal and natural methods are excluded), this percentage drops to 79 percent. Among modern methods, over half of these women had had sex with a partner who used condoms and about one-third had ever used an IUD or oral contraceptives. Other modern methods were rarely used. Over 70 percent of women in union had ever employed withdrawal with a partner to avoid pregnancy. One-third reported ever using any of the natural methods. 59 The percentage of women in union ever using any family planning method was virtually uncorrelated with respondents' ages. The proportion ever using a modern method, however, increases to ages 25-29 and then levels off. Ever use of the IUD, oral contraceptives, and sterilization, methods requiring a physician, were most strongly correlated with age. There was a strong, direct correlation between respondent education and ever use of contraception, such that 96 percent of women with a secondary school diploma and 98 percent of those who attended university had ever used a method. The only methods for which ever use did not increase with education were the IUD and sterilization. Current Use of Contraception Sixty-nine percent of women who were married or living with a man were using a family planning method at the time of interview (Table IV.3), a contraceptive prevalence rate slightly below the levels found in most other developed countries. There was relatively little difference in contraceptive prevalence between regions of the Czech Republic. The one region to stand out was South Bohemia, where only 55% of women in union reportedly were using a contraceptive method, 14 percentage points below the national figure. Couples with two or three children were the most likely to be using contraception (75% and 78%, respectively), while only 29% of childless couples were contracepting. This is another indicator that most couples still want to have a child as soon as they marry. As with ever use, current contraceptive use increased with level of education, at least up to the level of secondary school completion. Women not affiliated with an organized religion were somewhat more likely to be using than women who belonging to a religion. Somewhat surprisingly, there was virtually no difference in contraceptive prevalence between Catholics who regularly attended church and those who did not (both 64%). Women affiliated with religions other than Catholicism (mainly Protestants of assorted denominations) were the least likely to report that they were practicing contraception (59%). Overall, the most commonly used contraceptive methods were reported to be withdrawal (19% of all respondents), condoms (15%), and the IUD (12%), which together accounted for just over four-fifths of all contraception (Table IV.4). Oral contraceptives were the fourth most common method, used by about 8% of all women. No other methods were currently employed by more than 2% of women. About 2% of women had been contraceptively sterilized. No respondents reported that their partner had undergone a vasectomy. Because most contraceptors were women currently in union, the mix of methods used among them is similar to the population as a whole (Figure IV.1). Although only 46% of previously married women were using contraception, those who were using were more likely to employ an IUD or oral contraceptives than were currently married users. Among women who had never been married, 38% were using some method of pregnancy prevention. However, within this group over three-fourths of users relied on 60 61 condoms, withdrawal, or both. Withdrawal was the most commonly used method regardless of the number of living children, except among those with four or more children, among whom contraceptive sterilization was most widely used (27%) (Table IV.5). Relative reliance on modern methods grew as number of children increased (Figure IV.2). Condom use was slightly less common than withdrawal regardless of the number of children. IUD use was most prevalent among women with at least two children, among whom it was the second most widely used method. Oral contraceptive use was highest among women with between one and three living children. The relationships between age and contraceptive use (Table IV.6) appear to be, to a large extent, a function of the number of living children, rather than just age itself. The percentage of couples using withdrawal or condoms is relatively constant across all ages. The IUD, a method used primarily to limit childbearing in the Czech Republic, was relatively flat from ages 25-29 to 40-44. Oral contraceptive use is highest at ages 20 to 34, after which it declined sharply. The only strong relationship apparent between contraceptive use and education was that condom use increased with educational level (Table IV.7). The highest proportion of sterilized women (5%) was among those with no secondary school education. The use of natural family planning methods appears to increase somewhat with increasing education. Most of the difference in contraceptive prevalence between women espousing no religion and others was accounted for by much higher use of oral contraceptives among the former (Table IV.8). The level of use of withdrawal and condoms was almost indistinguishable between groups. Not surprisingly, the use of natural methods (NFP) was most widespread among Catholic women who regularly attended church, but even among this group only 5% of all women and 7% of contraceptors were utilizing NFP. Table IV.9, which is restricted to respondents who were fecund, in union, were not pregnant and did not want to become pregnant at the time of interview, compares contraceptive use between those who wanted no more children (limiters) and those who wanted to delay their next pregnancy (spacers). Overall contraceptive prevalence in these two groups was virtually identical (82% and 81%, respectively). Limiters were considerably more likely to be using an IUD (20% versus 9%) or female sterilization (4% versus 0%). Reported levels of use of oral contraceptives, withdrawal, and condoms were slightly higher among spacers than limiters. Source of Contraception There is no national family planning program in the Czech Republic, nor does the government distribute contraceptive methods. Oral contraceptives must be prescribed by a gynecologist, while lUDs must also be prescribed and inserted by gynecologists. These methods have, until recently, been available almost free of charge. With the 62 63 changes underway in health care financing, the costs of these methods to consumers are likely to increase (Visser, Uzel et al. 1993). Condoms are available from pharmacies and other commercial outlets. Table IV.10 displays distributions of reported sources of oral contraceptives and lUDs according to the respondents' region of residence. Sixty-one percent of pill users obtained them from regional or district physicians, with 17% getting their supplies from pharmacies (information was not available on the physicians from whom these women received their prescriptions), 11% using polyclinic physicians, and 8% using private physicians. The percentage using regional or district physicians ranged from 80% in Prague to 41% in Central Bohemia. Most women currently using an IUD had the device inserted at either a regional or district clinic (47%) or at a hospital (35%). Only 2% obtained their IUD from a private physician, a much lower percentage than for oral contraceptives. The proportion using regional/district physicians ranged from 70% in Prague down to only 25% in South Moravia. South Moravia had the highest proportion of IUD insertions at hospitals (56%) and Prague had the lowest (8%). Reasons for not Using Contraception Respondents who were not using a family planning method at the time of interview were asked to state their most important reason for not employing a method. About two-thirds of these women gave reasons that related to either a lack of current sexual activity (38%) or their pregnancy status (i.e., subfecund, trying to become pregnant, or currently pregnant) (Table IV. 11). Among the broad assortment of other reasons given, the most common was fear of health effects related to contraception (7%). About 11 % of women said they were not using because they thought it was difficult for them to get pregnant, because they were having sex only sporadically, or because they were postpartum or breastfeeding, indicating they felt that contraception was not very necessary. Religion and inability to obtain methods were rarely mentioned; even among Roman Catholics, fewer than 1 % said that religion was their major reason for non-use. Based on the results in this table, it appears that almost one-third of Czech women who were not using contraception may have been at some risk of unintended pregnancy due to non- use of contraception. Not surprisingly, a lack of sexual activity was the principal reason for not using among those not currently married. Among those in union, just over half of nonusers reported a reason related to pregnancy status or sexual activity. Reasons such as fear of health effects, difficulty in getting pregnant, and postpartum/breastfeeding were much more common among these women than among those not in union. 64 Contraceptive Failure/Discontinuation The 1993 CRRHS contained a contraceptive use/pregnancy calendar which tracked women's contraceptive histories from the beginning of 1988 to the date of interview. This allowed estimates to be made of yearly failure and discontinuation rates for each commonly used contraceptive method in the Czech Republic. Because of substantial underreporting of induced abortions in the survey (See Chapter III) we assume that failure rates and, to a lesser degree, discontinuation rates calculated from the reported histories of respondents are too low. It appears that reporting of pregnancies not resulting in abortion was virtually complete, but that about half of the 40-45 percent of pregnancies ending in abortion were omitted from the pregnancy histories. Therefore, we estimate that overall contraceptive failures are underestimated by about 20 to 25 percent. There is no obvious reason to expect a correlation between the method used at the time of failure and whether the failure was reported, so we assume that the failure rate for each method is on the order of 25 percent higher than presented in Table IV.12. The 12 month failure rates presented in Table IV.12, especially when adjusted for underreporting of abortions, are very much in line with rates typically reported for these methods, both worldwide (Trussell and Kost 1987) and in eastern Europe (Romania Institute for Mother and Child Care 1995). After adjusting for underreporting, we estimate pregnancy rates within one year of about 3% of pill users, 4% of IUD users, 7% of condom users, 15% of withdrawal users, and 26% of NFP users. Table IV.12 also displays unadjusted rates after 24 and 36 months. Table IV.13 presents 12, 24, and 36 month contraceptive discontinuation rates. These figures represent the probability that a couple beginning use of a particular method would no longer be using that method after a given duration, regardless of the reason for stopping. These rates should only be slightly affected by any underreporting of abortion, since discontinuation occurs for many reasons other than unintended pregnancy. Of the five methods examined, discontinuation of the IUD was far lower than for the others, with only 13% stopping use in the first 12 months. Even after three years, three-fourths of IUD users continued using. Rates of discontinuation for the other four methods in common use were extremely similar to each other. Although the percentages in Table IV. 14 cannot be used to estimate rates of discontinuation for specific reasons, they do give a good idea of the relative contributions of various reasons to method termination. Overall, pregnancy accounted for about one-fourth of reported terminations (even more if unreported abortions are taken into account), followed by stopping in order to become pregnant (20%) and inconvenience of the method (16%). However, the relative importance of the reasons for discontinuation varied greatly for different methods. Among oral contraceptive users, side effects accounted for 27% of discontinuation, followed by physician recommendations (20%), health concerns (14%), and a desire to become pregnant (13%). Among IUD users, physician recommendations were the overwhelming reason 65 for stopping (42%), followed by side effects (23%), and pregnancy (19%). Reasons for condom discontinuation were more evenly spread between method inconvenience (26%), desire for pregnancy (23%), and method failure (18%). Most withdrawal users terminated because of pregnancy (32%), desire for pregnancy (22%), or inconvenience of the method (15%). Need for Family Planning Services The concept of "women in need of family planning services" is one that is useful in determining the extent to which such services are reaching those who are at risk of becoming pregnant, but who would prefer not to. In Table IV.15 two different definitions are used to estimate the proportion of women of childbearing age in need of family planning services. The first definition (A) considers women in need to be those who are in a sexual union, are not currently pregnant, are fecund, are not using any form of contraception, and do not want to become pregnant. Definition (B) also counts as in need women who are using withdrawal or natural family planning methods, because of the lower effectiveness of these methods (See Table IV. 12). According to these two definitions, 10% and 31%, respectively, of Czech women of reproductive age were in need of family planning services at the time of interview. When definition A was used, women in need increased with age and number of living children and decreased as education and income (except for the lowest category) increased. The proportion in need was lowest among those with no religion. When definition B was used, most of the differentials noted disappear, indicating that most differences could be attributed to greater use of withdrawal in certain groups. Using this definition, we see that there were no appreciable differences in women in need according to place of residence, education, religion, or income. Even across age and number of children categories almost all differences disappeared, except that childless women were less likely than others to be in need. Use of Less Effective Methods Even though overall contraceptive prevalence is high in the Czech Republic, we have seen that there is considerable reliance on the use of methods of relatively lower effectiveness, particularly withdrawal. This reliance on less effective methods is, no doubt, one of the key factors in bringing about high rates of induced abortion in the Czech Republic. If all contraceptors were to use highly effective methods there would be relatively low levels of unmet need for family planning services. Women who were avoiding pregnancy through the use of withdrawal (including withdrawal in combination with condoms) or natural family planning (NFP) methods were asked a series of questions regarding their method choice. Each woman was asked how important each of six factors was in the couple's selection of their current contraceptive method. The results of these questions, displayed in Table IV.16 and 66 67 Figure IV.3, demonstrate that only a fear that negative health effects are associated with the use of modern methods was an important consideration in the selection of withdrawal and NFP. Forty-four percent said that fear of health effects was very important and an additional 31% said it was somewhat important in making their decision. Among the other five factors, partner's preference was easily the most important, considered very important by about one in every ten instances. Cost, availability, and knowledge of other methods were each very important to 3-4% of women, while religious factors were not a consideration at all for 97% of these women. Health considerations were important in choosing a contraceptive method for a large proportion of less effective method users in all age and education categories (Table IV.17). However, they were somewhat less important among women under 25 years of age. Cost, availability, and knowledge of methods were less likely to be reported as important factors as both age and education increased, so that few older or well educated women said they were at all important. The only group among which more than 5% said religion was important were those using NFP. As shown in Table IV. 18, almost half of users of less effective methods thought that their method was at least as effective as more modern methods, such as oral contraceptives and the IUD. Only one woman in three felt that her method was less effective. With increasing age there was a decreasing proportion of women who recognized the poorer reliability of their current method, As might be expected, the percentage recognizing the lower effectiveness of withdrawal and NFP increased sharply with education, from 18% to 41 %. There was little difference between the opinions of withdrawal and NFP users. Problems with Current Contraceptive Methods Based on responses to a question asked of all contraceptive users regarding the most significant problems or concerns they had with their current contraceptive method, it appears that most women are relatively happy with their method. Eighty-five percent said they had no major problems. This figure was fairly consistent between methods, ranging from 90% for NFP down to 80% for a combination of condoms and withdrawal (Table IV.19). Overall, about half of those with concerns reported that reliability/ quality was their major one. Small numbers of women reported health concerns, inconvenience, and side effects as problems. Reliability was especially a concern of withdrawal user and, to a lesser extent, among NFP and condom users. Health concerns were rare except among oral contraceptive (8%) and IUD (5%) users. Consistent with this low level of reported concerns about current methods, 73% of current contraceptors stated that they would prefer to continue using their current method rather than switching to another one (Table IV.20). This percentage was fairly constant across users of most methods, except for IUD users, 90% of whom were satisfied with their method, and users of a combination of condoms and withdrawal, among whom only 54% preferred their current method(s). 68 Among those desiring to switch from their current method, the greatest number preferred to use oral contraceptives (40%), followed by the IUD (25%). Surprisingly, the third most preferred method (15% of those preferring another method) was implants, which were not yet available in the Czech Republic at the time of the survey. Of IUD users preferring to switch methods, 41% favored implants and an additional 25% preferred sterilization, either female or male. Few women wanted to switch from their current method to condoms, withdrawal, or natural methods. Contraceptive Sterilization Unlike many other countries of the world with high rates of contraceptive prevalence, the formerly communist states of central and eastern Europe have very low rates of surgical sterilization, both tubal ligation and, to an even greater extent, vasectomy. As was demonstrated earlier in this chapter, the Czech Republic is not an exception; sterilization is not widely practiced there. A major factor in the low prevalence of surgical sterilization in the Czech Republic is a law that prohibits the procedure for women with fewer than four children. Only three percent of married women of childbearing age report having undergone surgical sterilization, while no women report their partners to have undergone a vasectomy. Despite the facts that most women complete their desired childbearing many years before becoming unable to bear children and that contraception is widely practiced, relatively few women have been willing and able to become surgically sterilized. The major exception is the relatively small group of women who have at least four living children, over one-fourth of whom had been sterilized. The CRRHS questionnaire included several questions designed to learn more about the reasons for the infrequency of tubal ligation and to gauge the interest in this procedure among Czech women. The results displayed in Table IV.21 and Figure IV.4, when viewed in conjunction with the small proportion of sterilized women, demonstrates a lack of interest in the procedure. Among the 2,345 respondents who desired no more children, only 8% said they were interested in undergoing tubal ligation, in addition to the 3% already sterilized. Another 7% were not sure whether they would consider it. Four out of every five women said they would not consider the procedure, despite reporting a desire to terminate childbearing. The low level of interest exists throughout the surveyed population (except, as mentioned among those with four or more children), with the proportion either already sterilized or interested in sterilization not exceeding 15% for any geographic, age, educational, or religious category examined. Respondents reported a variety of reasons for not being interested in surgical sterilization (Table IV.22). The leading response, given by about one of every three women claiming not to be interested, was simply that they had not thought about undergoing the procedure. This is a strong indication that the low levels of sterilization stem not so much from a conscious decision not to be sterilized as it is from the fact that it has not been made available or discussed by health care providers as an option and that the 69 70 population knows little about the procedure. The second most commonly given response was a fear of health risks associated with the procedure (20%). This was followed by the fear that the woman/couple may decide to have another child (12%) and a fear of surgery (11 %). No other reason was mentioned by more than 4% of respondents wanting no more children. It is interesting to note that despite the opposition of the Catholic church to the procedure, only 1 % of women reported religious grounds for their lack of interest. There were only minor differences in the reasons given for women of different educational attainment. As education increased women were more likely to say they were worried about health risks or might want another child and less likely to cite a fear of surgery or objections of their husband. There were several noteworthy differences between the characteristics of surgically sterilized women and the survey sample as a whole (Table IV.23). Of course, sterilized women tended to be older (two-thirds between ages 35 and 44) and have more children (97% with at least two) than the general population of 15-44 year-old women. In addition, though, about equal numbers of sterilized women lived in Bohemia and Moravia. One-third of sterilized women never went beyond primary school, even though this was true of only 18% of all respondents. Many sterilizations take place relatively early in women's lives: 45% of sterilized respondents had the procedure before the age of 30. Use of Infertility Services In trying to have the number of children they desire, couples often have need of services that help them to increase the likelihood of conceiving and bearing a living child, not just services that will help them to prevent conception and childbirth. The CRRHS included a module on the use of infertility services by respondents and their partners. As shown in Table IV.24, 13% of women who had ever been in union had used infertility services at some point in their life, two-thirds of those before 1988. There was little difference in the proportion who had used these services according to respondent characteristics. The university educated respondents appear slightly less likely than others to have used infertility services. Table IV.25 displays the percent of those seeking infertility services from a physician or clinic who received specific types of treatment or advice. The most common service rendered was providing women/couples with advice on timing intercourse so as to maximize the probability of conception (54%). Forty percent of women and 37 percent of their partners had various tests performed on them. Thirty six percent had drugs prescribed to help them with their infertility problem, 21% were advised to try bed rest, the same percentage who reported that they underwent some type of surgical procedure. It appears that respondents in Moravia were more likely to undergo medical interventions than those in Bohemia. Among women seeking help for infertility, Moravian women were more likely to report having drugs prescribed, having surgery, or undergoing in vitro fertilization. As women become older it appears they are more 71 likely to receive medical interventions for their problem. Testing of both women and partner, surgery, the use of drugs, and especially in vitro fertilization are most common among those seeking treatment at ages 35 to 44. 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 V. PREGNANCY, DELIVERY, AND INFANT HEALTH The 1993 CRRHS included a module, administered to all respondents who had given birth since the beginning of 1988, on maternal and child health issues related to her most recent pregnancy and live birth. The topics covered in this module included: reactions to learning she was pregnant; stress and physical activity during pregnancy; prenatal counselling; amount, timing, and source of prenatal care; use of ultrasound; complications/hospitalization during pregnancy; use of cigarettes and alcohol during pregnancy; birth weight; type of delivery; information on the delivery (including type of delivery, analgesia, and quality of care issues); and problems encountered after the child's birth. Unlike reproductive health surveys in developing countries, the 1993 CRRHS did not have as its objectives the measurement and detailed analysis of infant morbidity and mortality. The national medical statistics system compiles detailed and virtually complete information on infant deaths in the Czech Republic and collects information on other aspects of infant morbidity and mortality as well. Infant mortality in the Czech Republic in 1993 was reported to be about 9 deaths per 1,000 live births. This level was lower than the rate reported for any other former communist country in Europe. However, the rate was still slightly higher than for most western European countries. Even though it was not necessary for the survey to measure infant and early childhood mortality, it was decided that it was important to collect information on factors known to be related to the health of infants, most of which are not routinely included in the medical statistics system. These factors include such things as breastfeeding, cigarette smoking during pregnancy, and use of prenatal services. These data can be used to determine the prevalence of selected risk factors and to learn in which segments of the population is the health of infants most at risk from these factors. Reaction to Pregnancy Among those women who had a live birth since the beginning of 1988, about two-thirds said they were immediately happy about the pregnancy that resulted in their most recent birth (Table V.1). About one-fourth said they easily accepted the pregnancy, 8% eventually accepted it, and no women said they never accepted the pregnancy. Since we know there are many unintended pregnancies in the Czech Republic, we do not know the degree to which these results indicate that Czech women easily adjust to unintended pregnancies or that most truly unintended pregnancies are aborted. Poorly educated women were the least likely to be immediately happy about their pregnancy. The distribution of reactions to pregnancy among spouses/partners, according to respondents, was barely distinguishable to that among respondents themselves (Table V.2). A small percentage reportedly never accepted the pregnancy. As with 97 respondents, poorly educated men were the least likely to be immediately happy. Physical Exertion/Stress during Pregnancy Heavy physical exertion and emotional stress are thought by some to increase the risk of adverse pregnancy outcomes. CRRHS respondents were asked about the extent of physical exertion, standing at their jobs, and on-the-job stress during their most recent pregnancy. Tables V.3, V.4, and V.5 display distributions of the degree of job-related heavy physical work, standing, and stress, respectively, during respondents' most recent pregnancy leading to a live birth. Overall, 15% of women described themselves as having done much physical work and 27% said they did a large amount of standing during their jobs. Not surprisingly, the amount of both physical exertion and standing decreased sharply as educational level increased. Physical exertion and standing were both least common among women in their twenties. Seventeen percent of women said they were under a large amount of stress on their jobs during pregnancy and 32% said they were under moderate stress. The proportion under great stress was much higher among university educated women (41%) than among others (11%-18%). Prenatal Care As seen in Table V.6, the Czech Republic has an impressive record regarding prenatal care coverage, which has become almost universal. Fewer than 1% of women with a live birth since the beginning of 1988 received no prenatal care during their most recent pregnancy leading to a live birth. Ninety-four percent of those women began receiving prenatal care during their first trimester, while only 5% waited until after the first trimester. (Of this 5%, most started receiving care in the fourth month of pregnancy.) The percentage of women not receiving early prenatal care, seen in Figure V.1, ranged from 3% in South Bohemia to 10% in North Bohemia and 9% in East Bohemia (both with 2% receiving no prenatal care). Receipt of prenatal care appears to be unrelated to the size of community. The groups of women who were less likely to begin care in the first trimester included those who: were less than 20 years of age or between 35 and 44 years, were not currently married, had only a primary education, were affiliated with a religion other than Catholicism, and had low household income. However, for only a few groups did the proportion receiving early prenatal care drop substantially below 90%: those belonging to "other" religions (83%) and those with only a primary education (87%). Not only did women tend to begin prenatal care early, but 91% reported making at least 10 prenatal visits during pregnancy, with only 1% reporting fewer than six visits (Table V.7). The proportion of women making at least 10 prenatal visits was high across all geographic and socioeconomic categories, but was especially high in Prague (97%) and 98 99 East Bohemia (95%). Almost two-thirds of those who made prenatal visits, reported that they received their care primarily from physicians, while one-third received care from both physicians and nurses/midwifes. Only 3% said that nurse/midwifes were their primary providers (Table V.8). Women from communities with fewer than 5,000 people were less likely than others to receive care primarily from physicians. Within regions the percentages primarily seeing physicians ranged from 70% in Prague to 54% in North Bohemia. Women at ages 15-19 and 40-44, as well as women with only a primary education, were much less likely than others to have received care principally from physicians. Sixty percent of women received their prenatal care primarily at a district clinic, with the remainder going to a combination of district clinics and hospitals, or mainly a hospital (Table V.9). Women were less likely to primarily utilize district clinics if they lived in larger cities (54%), lived in Prague (37%), or were 40-44 years old (45%). A large majority of women lived within 30 minutes of their usual source of prenatal care, regardless of their usual means of transportation, with a mean time to source of care of about 22 minutes (Table V.10). Only 1% of women required more than one hour to reach their care provider. Percentage distributions of usual waiting time to receive prenatal care during the most recent pregnancy ending in a live birth are displayed in Table V.11. Overall, 44% typically waited for over 30 minutes, while 15% waited for over one hour. Waiting time appears to be longer in medium sized places than in larger or smaller towns and cities. Of the regions in the Czech Republic, waiting time was the longest in West Bohemia and Central Bohemia, where over half of women typically waited more than 30 minutes for care. The shortest waiting times were in Prague. Interestingly, as women's level of education increased their reported waiting time tended to decrease. Ultrasound Examinations Ninety-two percent of women who received prenatal care reported that they underwent an ultrasound examination during their last pregnancy leading to a live birth (Table V.12). The percentage having no ultrasound exam varied from 2% in South Bohemia and 3% in South Moravia up to 15% in North Moravia and 14% in West Bohemia (Figure V.2). These differences indicate possible differences in providers' practices or regional availability of ultrasound. The procedure was more commonly done for the youngest (15-24 years) and oldest (40-44) groups of women. The proportion receiving no ultrasound exam also decreased with education, from 11% for women with primary education only to 3% for those who attended university. Despite the high ultrasound coverage, there was some concern that women were not being adequately informed of the purpose of these examinations. The CRRHS found that 100 101 one-fourth of women who had undergone ultrasound reported that no one had explained the reason for doing this procedure and another one-fifth had only had the procedure explained to them slightly (Table V.13). Women in small towns were the most likely to say the procedure had been explained well. Among the regions of the country, women received the least explanation in Prague and in East Bohemia. Mutiparous women were more likely than primiparous women to report having had the procedure explained to them, which may indicate that previous experience affects women's perceptions of how well procedures are explained. Women at ages 35-39 and 40-44, as well as well educated women, were much more likely than others to have had the procedure's purpose explained. Bed Rest/Hospitalization during Pregnancy Table V.14 reveals that about three of every ten women had bed rest prescribed for part of their most recent pregnancy resulting in a live birth. The percentage varied from 38% in North Bohemia to 23% in West Bohemia, with little variation in prescribed length of bed rest. On the other hand, while there was little difference by age in the percent for whom bed rest was prescribed, older women tended to have considerably longer bed rest prescribed. The likelihood of bed rest increased slightly with educational level. Hospitalization during pregnancy (other than for labor and delivery) is a common practice in the Czech Republic. Twenty-nine percent of women giving birth since 1988 were hospitalized during some part of their pregnancy, with a mean length of stay of almost one month and a median of two weeks (Table V.15). (It should be kept in mind that these figures exclude pregnancies not resulting in a live birth.) The percentage hospitalized is relatively high, but is not surprising in a system where there has been little economic pressure not to hospitalize individuals and where hospitalization provides an easy means of observing possible complications. There was relatively little geographic difference in the proportion hospitalized. Although older mothers were no more likely than others to be hospitalized during pregnancy, they tended to be hospitalized for the longest periods of time (mean = 57 days, median = 21 days). Primiparous women were slightly more likely to have been hospitalized than multiparous women. As shown in Table V.16, the conditions most commonly cited as being responsible for hospitalization during pregnancy were bleeding during the first half of pregnancy (39% of hospitalizations) and early or false labor (33%). Much less common were excessive swelling or edema (14%), hypertension related to the pregnancy (11%), and bleeding during the second half of pregnancy (11 %). Among those who were hospitalized, primiparous women were more likely than multiparous women to report being admitted with hypertension related to pregnancy or with early labor. Otherwise, conditions leading to hospitalization were similar in the two groups. Figure V.3 displays indicators of several key aspects of prenatal care from the CRRHS. 102 103 Smoking during Pregnancy Cigarette smoking during pregnancy has been demonstrated to be a risk factor for adverse pregnancy outcomes, particularly for low birthweight. Sixty-eight percent of respondents with recent live births were not smokers when they became pregnant (Table V.17). An additional 21% reported that they stopped smoking upon finding out they were pregnant, with the remaining 11% continuing to smoke during pregnancy. About one-third of this group smoked at least 10 cigarettes per day. Women in Bohemia (and particularly women in North Bohemia and Prague) were much more likely than women in Moravia to smoke during pregnancy (14% and 8%, respectively). As educational level increased, the likelihood that a woman smoked during pregnancy decreased sharply, from 32% among women with only a primary school education, to 2% for those who attended university. Birthweight/Pregnancy Outcomes The incidence of low birthweight (LBW) (i.e., under 2,500 grams) among recent births was 5.8% among survey respondents (Table V.18). This is the same as the official rate of 5.8% for 1991 derived from national statistics, evidence that the survey data are of high quality in this regard. As is usually the case, the incidence of LBW was higher among primiparous women (7%) than among mutiparous women (5%). Although this difference was not large, the LBW rate was lower among multiparous women in all but a few categories of survey respondents. The highest LBW rates were found in cities of at least 20,000 population, in North Moravia, among the oldest (40-44 year-old) and youngest (15-19 year-old), single, and poorly educated women. The incidence of low birthweight exceeded 6% only in North Moravia and Prague (Figure V.4). By excluding unintended pregnancies from our tabulations, we were able to examine the distributions of pregnancy outcomes for just those pregnancies that women planned to have. This allows us to examine pregnancies outcomes from a physiological perspective (i.e., without having to worry about how unintended pregnancies end). Eighty-seven percent of all intended pregnancies since the beginning of 1988 resulted in live births (Table V.19). The only noteworthy differences observed according to place of residence, age, or education were lower proportions of live births and higher proportions of miscarriages among 15-19 year-olds and 35-44 year-olds. The induced abortion proportion was also higher among 40-44 year-olds, but it is possible this is a result of slight misreporting of intendedness of pregnancies among these women. Labor and Delivery The CRRHS questionnaire also inquired into respondents' opinions regarding services received for recent pregnancies and deliveries. Women were asked their impressions about the facility in which they most recently delivered in regard to: distance from home, physical facilities, crowdedness, attentiveness of staff, and competence of staff 104 105 (Table V.20). Only small differences were noted according to parity. Each of the five characteristics was rated as "good" by between one-half and three-quarters of respondents. The characteristic eliciting the most "poor" ratings (20%) was crowdedness. About one in ten women were unhappy about the distance from home, the physical facilities, and the attentiveness of the staff. The aspect of care about which respondents were clearly the most satisfied was the competence of the staff. The one area where satisfaction could most easily be improved is attentiveness of staff. The results indicate a need for a better and differentiated approach of the professional staff toward patients. Table V.21 reveals that for 41% of respondents labor and delivery lasted less time than they expected, while for 27% it lasted longer than expected. Mutiparous women were more likely than primiparous women to have labor last shorter than they expected, probably a result of typically longer time of labor for first deliveries. About one-third of women experienced more pain during labor and delivery than they anticipated (Table V.22). Even among women who had delivered previously, 31% experienced more pain than expected. There was a slight decrease in those reporting more pain than expected as education increased. The fact that for so many women the labor and delivery experience was very different than they expected indicates a need for better preparation and education of women during the prenatal period. Overall, four-fifths of respondents said that they received adequate information regarding their pregnancy (Table V.23). Not surprisingly, multiparous women (who had previously gone through a full-term pregnancy) were somewhat more satisfied. Women from small communities tended to be more satisfied than women from larger cities, and older women were more likely to be satisfied than younger ones. There was no clear relationship between education and whether women thought they received enough information. The level of satisfaction with information provided about delivery was 68%, lower than for information about pregnancy (Table V.24). Among multiparae 72% were satisfied, compared with 61% of primiparae. As with pregnancy information, satisfaction tended to decrease with increasing size of place and increase with age. Satisfaction with information also was lowest for the most educated women, regardless of parity. Respondents who had a live birth since the beginning of 1987 were asked who they would like to be present and if they would be interested in home delivery, should they have another child. Although no figures are currently available, it is still relatively rare for a husband/partner to be in attendance at a woman's labor and delivery. Thirty-nine percent of women said they would like to have their partner present at their next delivery, while 59% preferred to have only the professional staff present (Table V.25). There was a very sizable difference in preferences according to respondents' ages, whereby the percentage wanting only staff members in attendance rose from 33% for 15- 19 year-olds to 83% for 40-44 year-olds. Poorly educated women were somewhat more 106 likely than others to want only staff members present. Relatively few women, regardless of characteristics, were interested in having a baby at home, rather than in a health facility (Table V.26). Eighty-eight percent of respondents were definitely not interested in home delivery, while 4% showed interest. There was no strong relationship apparent between interest in home delivery and the personal characteristics examined. Problems in the Post Partum Period When asked what their major problem was during the first week following delivery, 40% of respondents said they had no major problems (Table V.27 and Figure V.5). The problems most commonly mentioned related to the health and care of the baby (18%), the woman's own health (17%), and breastfeeding (11%). Those reporting they had no major problems were more likely to live in small communities, be between the ages of 35 and 44, not to have attended university, and to have had more than one child. Care of the child was mentioned most commonly by 15-19 and 40-44 year-old women and by women who had never been married. Breastfeeding concerns stood out as a problem among university educated and primiparous women, but were rarely mentioned by 35- 44 year-old women. When asked about their most important problem after returning home from the hospital, 58% of respondents said they had no major problems (Table V.28 and Figure V.6). The problems mentioned most frequently were her own health (10%), health of the child (8%), care of her child/children (7%), and home environment (5%). Women from small communities, 40-44 year-olds, and women who were multiparous were the most likely not to mention any problems. Their own health was most often mentioned by women from larger communities and women 40-44 years of age. Health of the child was a major concern among the youngest women and single women. Care of the child was most commonly mentioned by university educated and primiparous women, but rarely by multiparous women. Prenatal Counselling Overall, 24% of respondents attended prenatal counselling sessions before their last live birth and more than half of those attended fewer than four sessions (Table V.29). Attendance was higher in Moravia than in Bohemia, and was especially high in South Moravia. Women with only a primary school education were less likely than others to attend prenatal counselling. Primiparae were more likely to attend counselling and attended more sessions than multiparae. Breastfeeding Breastfeeding has long been known to have two important effects related to reproductive 107 108 109 health. First, by increasing exposure to maternal antibodies, by decreasing exposure to infection, and by improving nutrition, breastfeeding reduces morbidity and mortality among infants. Second, by delaying the return of ovulation, breastfeeding decreases the probability of conception, especially in the absence of use of effective means of contraception. Even though the magnitude of these effects are much less in developed countries like the Czech Republic than they tend to be in developing countries, the benefits of breastfeeding can still be substantial. Ninety-one percent of children born to respondents since the beginning of 1988 were breastfed for at least some period of time (Table V.30). The proportion of infants breastfed was highest for those whose mothers: were ages 25-29 at the time of interview (94%); had a secondary school diploma (94%) or had attended university (92%); or were Catholic (93%). The proportion breastfed was lowest for infants with mothers ages 15-19 (84%) or ages 40-44 (71 %). Despite the fact that relatively few infants were never breastfed, the mean duration of breastfeeding was short: 3.7 months for all children and 4.2 months for children who were reportedly breastfed (Table V.31). Although the survey data do not allow estimation of the duration of postpartum amenorrhea, it is unlikely that the short duration of breastfeeding causes more than a negligible reduction in rates of conception for the overall population. Mean durations of breastfeeding were longer among children of women with at least a secondary diploma than women without a diploma and were slightly longer among women ages 25-44 at the time of interview. 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 VI. YOUNG ADULT SEXUAL BEHAVIOR One section of the CRRHS questionnaire was devoted to examining issues of reproduction and sexuality among young adults, those between the ages of 15 and 24 years. The purpose of the questions asked of these young women was to describe the age at which women first have sexual intercourse, use of contraception, circumstances surrounding any premarital pregnancy, and related information. Despite the sensitive nature of the information requested, cooperation from respondents was extremely high: Only 2% of young women refused to answer questions regarding sexual activity. Initiation of Sexual Intercourse Using life table procedures, we estimated the median age at which females first had sexual intercourse and the proportion who had ever had intercourse before each age from 15 to 23 (Table VI.1 and Figure VI.1). The estimated median age at first intercourse was 17.5 years. It appears that the age at which females begin having sexual relations may have been decreasing, since the median age was 0.5 years less for those 15-19 years of age than for those five years older. It can also be seen that the percentage reporting sexual experience by each age from 15 to 18 was higher for the younger (15- 19 year) cohort than for the older (20-24 year) cohort. Sexual intercourse before age 15 was still quite rare for girls, with only 3 percent reported sexually experienced before their fifteenth birthday, although it may have been becoming more common. By about age 21, only 3% of women had not yet had sexual intercourse. Table VI.2 examines differences in the age at first sexual intercourse according to geographic variables, religion, and household income. (Education is not included in this analysis because so many young women were still attending school and for those respondents current educational attainment would be misleadingly low.) The overall percentages reporting sexual experience were 36% for 15-17 year-olds, 82% for 18-19 year-olds, and 98% for 20-24 year-olds. There were some noteworthy differences between subgroups for ages 15-17 and 18-19, but for 20-24 year-olds there was virtually no variation according to the characteristics examined. Bohemian women tended to become sexually active before Moravian women (39% experienced, as opposed to 31% among 15-17 year-olds). Likewise, women espousing no religion started sexual relations earlier than Catholics (37% compared with 32%). There was no clear relationship between household income and sexual experience. Clearly premarital sexual intercourse has become the norm throughout the Czech Republic. Over 99% of sexually experienced women (all but six respondents) first had intercourse before they were married (Table VI.3, upper panel). Eighty-four percent of these women said their first sexual relations were with their "boyfriend". Another 10% described their first contact as a "friend", while only 5% first had sexual relations with 148 149 their fiance. As age at first intercourse increases, the likelihood that the first experience was with a "friend" decreases, and with a fiance increases. Of sexually experienced young adults, about two-thirds first had sexual intercourse less than four months or four to six months after their relationship began (Table VI.3, lower panel). Relatively small proportions had intercourse the first time they met their first partner (5%) or more than 12 months after the relationship started (9%). As a rule, the younger the age at which the woman began sexual activity, the shorter was the length of the relationship when that activity started. Among those first having intercourse before age 16, 13% had sex the first time they met their first partner. This figure was only 2% for those who became sexually active after age 17. Contraception at First Intercourse Forty-two percent of young adult respondents or their partner reportedly used no form of contraception the first time they had sexual intercourse (Table VI.4). Those who first had sex before age 16 and those without a secondary school diploma were the least likely to use contraception (Figure VI.2). Residence and religion were not related to whether contraception was used. Among those who did use contraception, over 90% used either withdrawal or condoms, which is not surprising, given that these methods are readily accessible and do not require contact with a clinic or physician. Withdrawal and condoms were the predominant method used by young women, regardless of their characteristics. When asked why they did not use contraception at first intercourse, 44% of non-users said the reason was that they did not expect to have sex (Table VI.5). Another 27% said they did not think it was possible for them to become pregnant. The percentage responding that they did not expect to have sex decreased with increasing age at first sex, from 57% for those under 16 years to 35% for those over 17 years. The proportion saying they did not contracept because they did not have any contraceptive method with them increased with age, from 2% to 13%. Premarital Pregnancy It is important to keep in mind that underreporting of induced abortions (and, therefore, pregnancies terminated by induced abortion) is likely to have had a significant effect on the results presented on premarital pregnancies, especially if premarital abortions were even more likely than abortions within marriage to go unreported. We expect that the proportion of females experiencing premarital pregnancy was somewhat higher than reported and that the proportion of those women who went on to marry the man by whom they became pregnant may also have been understated. About one-half of 15 to 24 year-old respondents reportedly had ever been pregnant at the time of interview and 150 151 about half of those said they were not married at the time they first became pregnant. The top panel of Table VI.6 reveals that in about three-fourths of instances of premarital pregnancy the man by whom she became pregnant was her "boyfriend", with most of the remainder being a respondent's fiance. Among those respondents who were 18 or older the man was more likely to be a fiance than among those under 18. Seventy-three percent of unmarried women who became pregnant said they went on to marry the man by whom they became pregnant. The bottom panel of Table VI.6, shows that in about seven of every ten cases, respondents reported that their partner wanted to get married after learning of the pregnancy. Fourteen percent of men preferred that the woman get an abortion. Eight percent wanted the respondent to have the baby, but did not want to get married. Finally, 2% of women said that the man never learned of the pregnancy. When asked about the reaction of their parents after finding out about their pregnancy, 43% of women said they were encouraged to get married (Table VI.7). This proportion was highest among those women who were under 18 when they became pregnant. Thirty percent of parents did not interfere, i.e., they let the women/couple make the decision on their own. As might be expected this percentage was lowest for those women who were less than 18 years of age, 16%. Eleven percent thought the woman should have the baby without getting married, 9% encouraged abortion, and 6% did not know about the pregnancy. The proportion encouraging abortion was much higher for those becoming pregnant before age 18. Family Planning Discussions with Parents Finally, all 15 to 24 year-old respondents were asked whether their parents had ever discussed the use of pregnancy prevention methods with them. Sixty percent of women said they had never had such discussions (Table VI.8). Among the minority whose parents did talk to them about contraception, discussions first took place at a fairly late age: only 14% of respondents' parents discussed the issue with their daughter before she was 15 years old. There were no strong relationships apparent between whether such talks took place and respondent characteristics. Even where such relationships might have been expected, for example, between religious Catholics and others, and according to whether the respondent used a method when she first had sexual intercourse, no strong correlations appear. Women who used contraception the first time they had intercourse were slightly more likely than non-users to have had discussions about family planning with their parents. Those women who had never had sex prior to the time of interview tended to have discussions about family planning with their parents earlier than sexually experienced women. 152 153 154 155 156 157 158 159 160 VII. REPRODUCTIVE HEALTH KNOWLEDGE AND ATTITUDES Each respondent answered a series of questions regarding her knowledge and attitudes about several aspects of reproduction. These questions included opinions about the conditions under which abortion should be allowable, knowledge of the fertile period, opinions about the efficacy, safety, and side effects of oral contraceptives, and views about women's role. The results of these questions should prove useful for policymakers and for developing reproductive health education and promotion activities. Attitudes about Restrictions on Abortion As described in Chapter III, the rate of induced abortions in the Czech Republic has been high by world standards, with official statistics for 1992 showing that there were 48 abortions per 1000 15 to 44 year-old women and 78 abortions for every 100 live births. Abortion laws are permissive, although minor restrictions have been added in recent years and the cost of having an abortion performed has increased substantially. Eighty-five percent of reproductive age women thought that women/couples should have the right to decide whether to have a pregnancy terminated by induced abortion for any reason they choose (Table VII.1). Every segment of the population examined was opposed, by a wide margin, to legal restrictions on a woman's access to abortion. There were only small differences in opinions according to place of residence, size of place, age, and marital status. As education and household income increased, so did the proportion of women in favor of the right to choose abortion. Even among Catholics who attend mass regularly, seven of every ten women felt there should be no limitations on legal access to abortion (Figure VII.1). The denominator for Table VII.2 consists of only the 14 percent (657 women) of respondents who reported that there should be some restrictions on access to abortion. An overwhelming majority of these women felt that abortion was justified under certain circumstances. Only 4% felt that a pregnancy endangering a woman's life was not adequate grounds for abortion. The proportions rose to 11 % if there was risk of a fetal defect, 56% if the couple could not afford another child, and 70% if the woman was not married. Table VII.3 shows the overall percentages of respondents who felt that abortion was not justified and should not be available under each of the six circumstances listed in the previous table. These figures range from less than 1% when a pregnancy endangers a woman's life to 10% when a woman is not married. For the first four circumstances there were few differences between population segments. For the others restrictiveness decreased as education increased. Even most Catholics who attended religious services regularly, the group with the most restrictive views about abortion availability, felt that abortion was justified under each of the six circumstances asked about. 161 162 Knowledge of the Menstrual Cycle Each respondent was asked at what time during the menstrual cycle is a woman at the greatest risk of becoming pregnant. Fifty-five percent of respondents correctly said that the chance of pregnancy is greatest about halfway between menstrual periods (Table VII.4). This proportion is considerably higher than has been found in reproductive health surveys in developing countries. Knowledge was lowest among 15-19 year-olds (39%). It also increased sharply with increasing education, from 32% to 83%. Fortunately, those women using natural family planning (NFP) methods, the success of which depend on a woman/couple knowing when conception is the most likely to occur, have the best knowledge (75%), however, one of every four NFP users were unaware of the time that conception is most probable. Opinions about Oral Contraceptives Respondents were asked a series of questions in order to learn their opinions about oral contraceptives. Recall that in Chapter III it was noted that among women who were using generally less reliable methods of contraception a fear of negative health effects, especially from oral contraceptives, was overwhelmingly the most important factor in the decision to avoid use of modern methods of family planning. It has also been reported anecdotally that many Czech gynecologists still feel that hormonal contraception should be avoided or not used for extended periods because of potential health effects. A recent study found that most Czech gynecologists felt that low dose oral contraceptives were safe for nonsmokers under 35 years of age, but there was a significant minority, especially among older physicians, who thought they were unsafe (Visser, Uzel et al. 1993). The opinions of physicians is almost certain to have an effect on the views of women. The information presented here documents attitudes of all women of reproductive age regarding the reliability, safety, and perceived side effects of oral contraceptives. On the whole, many women underestimated the ability of oral contraceptives to prevent pregnancy. Only about half of respondents said that a women who took them correctly could be completely or almost sure that she would not become pregnant (Table VII.5 and Figure VII.2). One of every five women indicated that the reliability of oral contraceptives was quite low. There was relatively little variation across the population in opinions about reliability. Confidence in oral contraceptives increased with education. It was, not surprisingly, highest among oral contraceptive users, but otherwise was unrelated to whether a woman was contracepting. Overall, about one-fifth of women felt that oral contraceptives posed a substantial risk to women's health and a slightly smaller percentage said they did not know if they posed a risk (Table VII.6 and Figure VII.3). The percentage who felt that they were unsafe increased slightly with age and was highest among the least educated. One-third of Catholics attending services felt that oral contraceptives were unsafe, the highest 163 164 proportion of any population segment examined. Fifty-three percent of women were aware that oral contraceptives make menstrual periods more regular, while 42% felt that oral contraceptives cause weight gain (Table VII.7). Sizable minorities of respondents agreed with the statements that oral contraceptives: increase the risk of getting cancer (25%); are bad for blood circulation (21%); can cause infertility (16%); and cause nervousness (13%). For each of these four statements about one-half of respondents said they did not know whether they were true. Reliance on methods of low reliability (as well as unintended pregnancy and induced abortion rates) would be likely to decrease if women became more aware of recent evidence regarding the safety of oral contraceptives, especially of newer formulations. Women's Family and Reproductive Roles Respondents were asked whether they agreed or disagreed with five statements, shown in Table VII.8, regarding women's roles and reproduction. There was considerable agreement about the first three of these statements. Sizable majorities disagreed with the statements that "Child care is women's work" and "A woman should be a virgin when she marries", while agreeing that it is all right for a woman not to have children if she so desires. These results indicate that most Czech women do not feel that women should be restricted to traditional roles. Ninety-two and ninety-seven percent, respectively, correctly agreed that a woman could become pregnant the first time she has intercourse and that a condom should not be used more than once. 165 166 167 168 169 170 171 172 173 174 VIII. WOMEN'S HEALTH All respondents were asked a series of questions regarding selected knowledge and behaviors related to the general health of women. The topics on which they were questioned included: receipt of gynecologic exams; breast self-examination; cigarette smoking; alcohol consumption; and height and weight. These topics yield information about risk factors for various chronic diseases and the degree to which women are being screened for certain health conditions. Gynecologic Examinations It is recommended that women of childbearing age receive complete gynecologic examinations yearly. In the Czech Republic, the proportion of women having such exams is thought to be a good estimate of the proportion who receive Pap smears to screen for cervical cancer, since Pap smears are a routine component of these examinations. Sixty percent of respondents reported that they receive gynecologic exams at least yearly (Table VIII.1). At the other extreme, 15% of women said that they had never had such an exam. Bohemian women were somewhat more likely to receive yearly exams than Moravian women (63% versus 56%), with the differences between regions within Bohemia and Moravia generally small. The group least likely to be examined was 15-19 year-olds, among whom only 30% had yearly exams and 59% never had them. Beyond ages 20-24, almost all women had exams at least occasionally. Education was strongly correlated with receiving gynecologic exams, although there was little difference between women with a secondary school diploma and those who attended a university. Two-thirds of women who did not receive yearly exams said the reason for this was that they did not have any gynecologic problems (Table VIII.2). These women should be educated to the fact that all women ought to be examined regularly, and not just when problems are evident. The second most common reason given (13%) was that women did not like such exams. Another 9% felt that it was not necessary to go as often as yearly for exams. Breast Self-Examination Breast self-examination (BSE) can be a valuable tool, if done properly, for detecting possible breast tumors earlier than they might otherwise be found. In the CRRHS women were asked about their knowledge and use of this procedure. Slightly under half of all respondents said that they practiced BSE at least occasionally (Table VIII.3). Another 28% were familiar with BSE, but never practiced it and 26% were unfamiliar with BSE. Although their was little difference in reported BSE knowledge and practice according to place of residence, there were large differences by age and education. Use of BSE increased sharply with age, from 12% for 15-19 year-olds to 70% for 40-44 year- 175 olds. Use increased from 37% to 62% from the lowest to highest education categories. Cigarette Smoking It has been firmly established that cigarette smoking is an important risk factor for several forms of cancer, respiratory diseases, and cardiovascular disease, among other chronic conditions. Reducing smoking prevalence can play important role in increasing life expectancy and improving the overall health and quality of life of a population. Thirty percent of CRRHS respondents reported that they currently smoked (Table VIII.4). Another 12% had smoked in the past, but were no longer smoking. Smoking prevalence was highest in North Bohemia (40%) and Prague (38%) and lowest in Moravia (26%) and adjacent East Bohemia (27%). Rates also tended to be higher in large cities than elsewhere. Smoking prevalence increased with age up to ages 30-34 and decreased sharply as educational level increased (Figure VIII. 1). Interestingly, cigarette use was strongly related to marital status, with previously married women having the highest prevalence of any population subgroup examined (48%). This finding warrants further investigation to explain the reasons behind it. Only 19% of smokers were classified as light smokers, that is, they typically smoked fewer than five cigarettes per day (Table VIII.5). The largest proportion of smokers, 44%, smoked 10 to 19 cigarettes per day, while 16% were heavy smokers, smoking at least one pack per day. As a general rule, tobacco consumption was heavier among Bohemians than Moravians, among older women than younger women, and among poorly educated than well educated women. Previously married women not only had the highest smoking prevalence, but also were the heaviest smokers. Alcohol Consumption Because heavy alcohol consumption is also an important risk factor for a large number of health conditions, respondents were asked about the amount of beer, wine, and liquor they typically consumed. According to responses in the CRRHS, relatively few Czech women chronically consume large amounts of alcohol (Table VIII.6). Only 3% of respondents said that they consumed an average of more than seven alcoholic drinks per week. Moderate drinking is the norm, with almost eight of every ten women consuming either fewer than three or three to seven drinks per week, while one-fifth said they did not drink at all. The percentage of women in the highest consumption category was highest in Prague (5%) and North Bohemia (4%). It was not outstandingly high in any subgroup examined, being highest among previously married women (6%). These findings should be interpreted cautiously, however. First, alcohol consumption can often be underreported because society frowns on heavy consumption. Second, these figures do not give any information on acute alcohol use, where individuals tend to consume large amounts of alcohol on single occasions. 176 177 Overweight Being overweight is another factor that substantially increases the risk of many chronic conditions, such as cardiovascular disease, hypertension, and diabetes. Respondents were asked to report their height and weight. These data were used to compute each woman's body mass index (BMI), which is equal to weight (in kilograms) divided by squared height (in meters) to determine the degree to which women were overweight. A woman was considered to be substantially overweight if her BMI was at least 28.3 (Centers for Disease Control, 1988). Overall, 15% of respondents met this criterion (Table VIII.7). This percentage was lowest in Prague (10%). It tended to be highest in places with a population of less than 5,000 people (21%). As expected the percentage increased with age, from only 3% for women ages 15 to 19 to 29% for those ages 40 to 44. The proportion overweight fell sharply as education increased, such that only 5% of women who attended university were overweight. 178 179 180 181 182 183 184 185 IX. TRANSMISSION OF HIV/AIDS Since acquired immune deficiency syndrome (AIDS) was first recognized in the early 1980s, human immunodeficiency virus (HIV), the organism causing AIDS, has spread to all parts of the world. Even though, according to official statistics, the incidence of HIV infection was not yet very high in the Czech Republic at the time of the CRRHS, a threat of greatly increased spread of the infection existed. This was especially true in light of the increased numbers of people, especially tourists, entering the Czech Republic from other countries and the newfound freedom of Czechs to travel outside their own country following the fall of the communist government. The CRRHS included a series of questions intended to measure the knowledge of Czech women regarding HIV/AIDS in general and the means by which HIV is transmitted between individuals. Such information was designed to help determine where improvements in knowledge about AIDS was necessary in order to enhance the effectiveness of AIDS prevention programs. All but five respondents (99.9%) reported that they had heard of AIDS. Every respondent familiar with AIDS was asked whether they thought HIV could be transmitted by each of 12 different means. The proportions of women who felt that these were possible modes of transmission are shown in Table IX. 1. In general, there appeared to be a high level of awareness of those means by which HIV is known to be transmissible-sharing needles (98%), male homosexual relations (96%), and heterosexual relations (94%). Receiving a transfusion, which in some settings can lead to transmission, was felt to be a cause of AIDS by 89% of women. Almost half of women thought a person could be infected by giving blood or by going to a physician or dentist, behaviors that cannot transmit infection except under unusual circumstances. Among those methods asked about by which the virus is known not to be transmitted, the proportion who felt that HIV could be spread ranged from 28% for kissing on the mouth down to 3% for shaking hands. For everything except kissing on the mouth the proportion with correct knowledge tended to increase with increasing education. Only about three-fourths of respondents felt that condoms provided excellent or good protection against transmission of HIV (Table IX.2). There were only small differentials according to the characteristics examined in women's opinions about the effectiveness of condoms. There was a slight increase in perceived effectiveness as education increased and little relationship with place of residence, age, or marital status. Finally, even though CRRHS respondents were not asked about their own risk factors for contracting AIDS, they were asked their opinion about their own risk of becoming infected. Eighty-three percent of women felt they had no risk of becoming infected, 3% felt they had a low risk, and 5% felt they had a high risk (Table IX.3). There was very little variation in these percentages across the population. Well educated women were slightly more likely to see themselves as being at risk, but this is likely to reflect different considerations in assessing risk, rather than a higher incidence of risky behaviors. 186 187 188 189 REFERENCES Albert A, Bennett C, Bojar M. 1992. Health care in the Czech Republic: a system in transition. Journal of the American Medical Association, 267(18):2461-6. Althaus F. 1992. Replacement-level fertility has now become the rule in most of Eastern Europe. Family Planning Perspectives, 24(3):140-2. Blayo C. 1991. Contraceptive methods in Eastern Europe. Population, 46(3):527-46. Blayo C. 1993. Le role de I'avortement dans les pays d'Europe Centrale et Orientale. Proceedings of the 1993 International Population Conference. IUSSP, Liege Belgium, pp 235-252. Centers for Disease Control. 1988. Prevalence of Overweight in Selected States- Behavioral Risk Factor Survey. Morbidity and Mortality Weekly Report, 37:9-11. Czechoslovakia Federal Statistical Office. 1991. Preliminary Results of the Population and Housing Census. Prague. David HP. 1992. Abortions in Europe, 1920-91: a public health perspective. Studies in Family Planning, 23(1):1-22. David HP, Dytrych Z, Matejcek Z, Schuller V. 1988. Born Unwanted: Developmental Effects of Denied Abortion. Avicenum, Czechoslovakian Medical Press, Prague. Festy P. 1991. Fertility in Eastern Europe since 1970. Population, 46(3):470-509. Fialova L, Pavlik Z, Veres P. 1990. Fertility decline in Czechoslovakia during the last two centuries. Population Studies, 44(1):89-106. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology, sixteenth revised edition. Irvington Press, New York, pp 633-687. Institute of Health Information and Statistics. 1991. CSFR Health Statistics Yearbook 1991. IHSI, Prague. Ketting E. 1992. Family planning in Central and Eastern Europe. Planned Parenthood Europe (special issue), 21(2): 1-39. Kraus J. 1987. Research on family size planning--I. Demographie, 29(1):23-33. 190 Massaro TA, Nemec J, Kalman I. 1994. Health system reform in the Czech Republic. Journal of the American Medical Association, 271:1870. National Public Health and Hospital Institute. 1994. Partnerships in Health Care Central and Eastern Europe. Population Reference Bureau. 1994a, World population data sheet. Population Reference Bureau. 1994b, The World's Youth (data sheet). Raffel MW, Raffel NK. 1992. Czechoslovakia's changing health care system. Public Health Reports, 107(6):636-43. Romanian Institute for Mother and Child Care, Centers for Disease Control and Prevention. 1995. Reproductive Health Survey Romania 1993. Trussell J, Kost K. 1987. Contraceptive failure in the U.S.: a critical review of the literature. Studies in Family Planning, 18(5):237-283. United Nations. 1988-1992. Demographic Yearbook (various years). United Nations, New York. Uzel R, Ketting E, et al. 1992. Contraceptive Practice and attitudes of czech and Slovak women. Planned Parenthood Europe 21(2):14-17. Visser A, Uzel R, et al. 1993. Attitudes of Czech and Slovak gynecologists toward family planning. Advances in Contraception 9:351-362. World Fertility Survey. 1978. The Czechoslovak Fertility Survey. 1972. International Statistical Institute, Voorburg, Netherlands. 191 APPENDIX A SAMPLING ERRORS Survey estimates of percentages, proportions, means, or other measures are subject to two types of errors: sampling error and non-sampling error. Non-sampling 'errors can arise from many sources, most notably interviewer errors, inaccurate information given by respondents (intentionally or unintentionally), data processing errors, failure to administer the interview to the correct households or individuals, as well as other factors. Although efforts were made during the design, training and implementation of the 1993 CRRHS to minimize the incidence and severity of non-sampling errors, it is virtually impossible to eliminate all sampling error or to evaluate their importance statistically. Sampling error is a measure or the variability between all possible samples of a given size that could have been selected from the population being studied (in this case, women between the ages of 15 and 44 throughout the Czech Republic) using a given sample design. Sampling error is measured in terms of the standard error for a particular statistic, which is the square root of the variance of that statistic. The standard error can be used to calculate confidence intervals around estimated statistics. The confidence interval most commonly used is the 95 percent interval, which defines the range within which the actual percentage, mean, etc. falls, in the absence of all non-sampling error. The 95 percent confidence interval for a statistic is the estimated value plus or minus 1.96 (approximately two) times the standard error of the estimate. The standard errors of statistics estimated using a multistage sample design, such as that used in the 1993 CRRHS are more complicated to calculate and are larger than standard errors based on simple random samples. The software package SUDAAN (Research Triangle Institute, 1993) was used to compute the CRRHS standard errors with the appropriate statistical methodology. In addition to standard errors, SUDAAN was used to compute the design effect for each estimate, which is defined as the estimated ratio between the variance using the multistage cluster design actually used and the variance that would have resulted if a simple random sample had been used. Therefore, the design effect demonstrates the increase in the increased variability of an estimate (including the standard error and confidence interval) due to the use of a complex survey design. Standard errors, design effects, and 95% confidence intervals (the limits of which are P-2SE and P+2SE) are presented in Table A.2 for variables considered to be of major interest. For each variable, the definition and the population used for the calculation are presented in Table A.1. 192 193 194 APPENDIX B 1993 CZECH REPUBLIC REPRODUCTIVE HEALTH SURVEY Household questionnaire ID NUMBER REGION__________________________ DISTRICT________________________ BASIC CENSUS DISTRICT HOUSE NUMBER (red number) BUILDING NUMBER FLAT NUMBER STREET ADDRESS ____________________________ CITY/TOWN/VILLAGE _________________________ SIZE OF PLACE 1 LESS THAN 5,000 2 5,000-19,999 3 20,000+ VISIT RECORD Visit number 1 2 3 4 Date of visit Result* Interviewer Supervisor Day Month Day Month Day Month Day Month *RESULT CODES 1 Completed interview 2 No eligible females 3 Nobody at home 4 ndent not home Selected respo 5 Total refusal 6 Refusal by selected respondent 7 Unoccupied house 8 Respondent incompetent___________________ 9 Other _______________________________________ 195 1. How many families live in this household? families 2. How many people normally live in this household? people 3. How many females between the ages of 15 and 44 live in this household? females 4. For each of these women could you give me the following information: Line 1 2 3 4 5 6 First name Age Marital status Education Level Grade Marital status: Level: 1 Married 0 No school 2 Divorced 1 Primary 3 Separated 2 Secondary 4 Widowed 3 University 5 on't know Single 8 D 6 Consensual union 8 Don't know SELECTION OF INDIVIDUAL RESPONDENT: LAST DIGIT OF QUESTIONNAIRE Eligible Respondents 0 1 2 3 4 5 6 7 8 9 2 1 2 1 2 1 2 1 2 1 2 3 3 1 2 3 1 2 3 1 2 3 4 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 6 6 1 2 3 4 5 6 1 2 3 1993 CZECH REPUBLIC REPRODUCTIVE HEALTH SURVEY Individual questionnaire TIME STARTED: : ID NUMBER Background characteristics 100. In what month and year were you born? Month Year 19 101. How old are you? years old (MAKE SURE THAT AGE AND DATE OF BIRTH CORRESPOND) 102. What is the highest grade in school you completed? 1 Primary 1 2 3 4 5 6 7 8 9-->GO TO Q104 2 Secondary 1 2 3 4 5+ ------ >GO TO Q103 3 University/Faculty 1 2 3 4 5+ ------- >GO TO Q104 103. Did you receive a diploma? 1 Yes 2 No 104. Are you currently married, living with someone as if married, separated, divorced, widowed, or single? 1 Married \ 2 Living with a man \ 3 Separated \--GO TO Q106 4 Divorced / 5 dWidowe / 6 Single --- >GO TO Q105 105. Have you ever been married or lived with a man? 1 Yes--->CORRECT Q104 AND GO TO Q106 2 No-->GO TO 200 SERIES 106. How many times have you been married or lived with a man? times 107. In what month and year did you begin living with your (first) husband/partner? Month Year 19 __ 108. What was the highest grade in school that your (first) husband/partner completed? 1 Primary 1 2 3 4 5 6 7 8 9---->GO TO Q110 2 Secondary 1 2 3 4 5+ ---------->GO TO Q109 3 University/Faculty 1 2 3 4 5+ ---------->GO TO Q110 8 Don't know ------------------------------->GO TO Q110 109. Did he receive a diploma? 1 Yes 2 No 110. When you first got married, how many children did you plan to have? __ Children 66 As many as possible 88 Were not sure 4 Fertility/Pregnancy 200. Have you ever been pregnant? 1 Yes 2 No 3 Not sure 201. Are you currently pregnant? 1 Yes ------>GO TO Q201A 2 No 3 Not sure IF CURRENTLY PREGNANT (Q201=l) GO TO Q201A IF PREGNANT IN THE PAST (Q200=l AND Q201 NOT 1) GO TO 202. IF NEVER PREGNANT (NEITHER Q200=l NOR Q201=l) GO TO Q224. 201A. Thinking back to when you became pregnant, did you want to become pregnant then? 1 Yes ------ >GO TO Q202 2 No ------- >GO TO Q201B 3 Not sure - >GO TO Q202 201B. Was it that you wanted to wait longer to become pregnant or that you wanted no more children? 1 Wanted to wait longer 2 more children Wanted no 3 Not sure 202. Have you ever had any live-born children? 1 Yes 2 No --->GO TO PREGNANCY HISTORY, Q210 203. How many living children do you have, including those who do not live with you? children IF 0 LIVING CHILDREN, GO TO Q206 204. How many of these are boys? boys 205. How many of these are girls? girls MAKE SURE THAT THE NUMBER OF BOYS AND GIRLS ADD UP TO THE TOTAL NUMBER OF CHILDREN (Q204 + Q205 = Q203). 5 206. Have you ever had any live-born children who later died, including any who lived only a very short time after birth? 1 Yes 2 No ---->GO TO Q209 207. How many boys have died? boys 208. How many girls have died? girls 209. So, altogether you have had (Q203 + Q207 + Q208) live births? 1 Yes 2 No--->PROBE AND CORRECT Q203, Q207, Q208 AS NECESSARY 6 7 PREGNANCY HISTORY Now I would like to talk to you about your pregnancies. Please make sure you include all past pregnancies, regardless of when they occurred and how they ended, whether in a live birth, an abortion, a miscarriage, or a stillbirth. Starting with your most recent pregnancy, please give me the following information: 210 210A 211 212 213 214 215 216 Order Was this a multiple pregnancy ? When did this pregnancy end? (Month & year) How many months did this pregnancy last? How did this pregnancy end? Was this child a boy or a girl? Is this child still alive? At1 what age did he/ she die? 1 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth -- >Q214 2 Stillbirth -- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 2 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth -- >Q214 2 Stillbirth -- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 3 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth -- >Q214 2 Stillbirth -- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 4 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth -- >Q214 2 Stillbirth -- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 8 5 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth-- >Q214 2 Stillbirth-- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 6 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth-- >Q214 2 Stillbirth-- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 210 210A 211 212 213 214 215 216 Order Was this a multiple pregnancy ? When did this pregnancy end? (Month & year) How many months did this pregnancy last? How did this pregnancy end? Was this child a boy or a girl? Is this child still alive? At1 what age did he/ she die? 7 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth-- >Q214 2 Stillbirth-- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 8 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth-- >Q214 2 Stillbirth-- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 9 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth-- >Q214 2 Stillbirth-- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 10 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth-- >Q214 2 Stillbirth-- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 11 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth-- >Q214 2 Stillbirth-- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months 10 12 l=Single 2=Twins 3 = 3 + 8=DK Month Year 19 months 0=Don't know 9 = 9 + 1 Live birth-- >Q214 2 Stillbirth-- >NEXT PREGNANCY 3 Miscarriage-->NEXT PREGNANCY 4 Extrauterine->NEXT PREGNANCY 5 Induced abortion-->NEXT PREG 1 Boy 2 Girl 1 Alive- >NEXT PREG 2 Dead Years Months AFTER FILLING IN ALL PREGNANCIES: IF NO PREGNANCIES ENDED SINCE THE BEGINNING OF 1988 GO TO 300 SERIES. IF ANY PREGNANCIES ENDED SINCE THE BEGINNING OF 1988 GO TO Q217. 11 QUESTIONS 217-223 ONLY FOR PREGNANCIES THAT ENDED IN 1988 OR LATER 217 218 219 220 221 222 223 COPY LINE # FROM Q210 Thinking back to when you became pregnant that time, did you want to become pregnant? Was it that you wanted to wait longer to become pregnant or that you wanted no more children? Did you breastfeed him/her? Are you still breastfeedi ng? How many months did you breastfeed? What was the most important re'ason that you decided to have an abortion? (CODES BELOW) 1 Yes---- >Q219 2 No. >Q218 3 Not sure---- >Q219 1 Wait longer 2 Wanted no more 3 Not sure IF LIVE BIRTH -- >Q220 IF INDUCED ABORTION -- >Q223 IF NOT A LIVE BIRTH -- >NEXT LINE 1 Yes 2 No-- >NEXT LINE 1 Yes --- >NEXT LINE 2 No months- ->NEXT LINE 1 Yes---- >Q219 2 No. >Q218 3 Not sure---- >Q219 1 Wait longer 2 Wanted no more 3 Not sure IF LIVE BIRTH -- >Q220 IF INDUCED ABORTION -- >Q223 IF NOT A LIVE BIRTH -- >NEXT LINE 1 Yes 2 No-- >NEXT LINE 1 Yes --- >NEXT LINE 2 No months- ->NEXT LINE 1 Yes---- >Q219 2 No. >Q218 3 Not sure---- >Q219 1 Wait longer 2 Wanted no more 3 Not sure IF LIVE BIRTH -- >Q220 IF INDUCED ABORTION -- >Q223 IF NOT A LIVE BIRTH -- >NEXT LINE 1 Yes 2 No-- >NEXT LINE 1 Yes --- >NEXT LINE 2 No months- ->NEXT LINE 1 Yes---- >Q219 2 No. >Q218 3 Not sure---- >Q219 1 Wait longer 2 Wanted no more 3 Not sure IF LIVE BIRTH -- >Q220 IF INDUCED ABORTION -- >Q223 IF NOT A LIVE BIRTH -- >NEXT LINE 1 Yes 2 No-- >NEXT LINE 1 Yes --- >NEXT LINE 2 No months- ->NEXT LINE 1 Yes---- >Q219 2 No. >Q218 3 Not sure---- >Q219 1 Wait longer 2 Wanted no more 3 Not sure IF LIVE BIRTH -- >Q220 IF INDUCED ABORTION -- >Q223 IF NOT A LIVE BIRTH -- >NEXT PAGE 1 Yes 2 No-- >NEXT PAGE 1 Yes --- >NEXT PAGE 2 No months- ->NEXT PAGE CODES FOR Q223: 1 Delivery dangerous to her health/life 2 Fetus diagnosed with defect/high risk of defect 3 Had all the children she/they wanted 4 Wanted to wait longer for next child 5 Could not afford another child 6 Husband/Partner wanted her to have abortion 7 Not married/No partner 8 Relationship ended 9 Parents wanted her to have an abortion 20 Other (specify)_______________________________ 88 Don' t know 99 No response GO TO NEXT PAGE (300 SERIES) 224. Have you ever had any pregnancies that ended with an abortion, a miscarriage, or a stillbirth? 1 Yes -->RETURN TO PREGNANCY HISTORY, Q202 2 No 12 13 Family Planning For each of the following methods of preventing pregnancy, please tell me: METHOD 300. Have you ever heard of it? 301. Have you ever used it? 302. Do you know where to get it? A. Pills 1 Yes-->Q301 2 No--->B 1 Yes 2 No 1 Yes 2 No B. IUD 1 Yes-->Q301 2 No -- >C 1 Yes 2 No 1 Yes 2 No C. Condoms 1 Yes-->Q301 2 No -- >D 1 Yes 2 No 1 Yes 2 No D. Foam/Jelly/ Cream 1 Yes-->Q301 2 No--->E 1 Yes 2 No 1 Yes 2 No E. Diaphragm 1 Yes-->Q301 2 No--->F 1 Yes 2 No 1 Yes 2 No F. Female Sterilization 1 Yes-->Q301 2 No-- >G 1 Yes-->G 2 No - >Q302 1 Yes 2 No G. Male Ster. (Vasectomy) 1 Yes-->Q301 2 No-- >H 1 Yes 2 No H. Fertile days method (Rhythm) 1 Yes-->Q301 2 No-- >I 1 Yes 2 No I. Withdrawal 1 Yes-->Q301 2 No-- >J 1 Yes 2 No J. Other 1 Yes-->Q301 2 No-- >Q303 1 Yes 2 No 303. RECORD WHETHER RESPONDENT REPORTS HAVING USED ANY METHOD (ANY 1 FOR Q301) 1 Never used - >GO TO Q304 2 Ever used--- >GO TO Q305 304. So, you have never used any of the methods of preventing pregnancy that I just mentioned with any partner? 1 Never used - >GO TO Q328 2 Ever used - >CORRECT Q301 AND GO TO Q305 305. Are you (or your partner) currently using any method or doing anything to prevent pregnancy? 1 Yes 2 No--->GO TO Q321 306. What method are you using? 1 Pills -- >GO TO Q308 2 IUD ---- >GO TO Q308 3 Condoms ---- >GO TO Q309 4 Foam/Jelly/Cream ---- >GO TO Q308 5 Diaphragm---- >GO TO Q308 6 Tubal ligation-- >GO TO Q307 7 Vasectomy------- >GO TO Q307 8 Fertile days ---- >GO TO Q311 9 Withdrawal " 10 Other _______________ " 11 Condoms + Foam/Jelly --- >Q309 12 Other combination__________" 307. In what month and year was this operation performed? Month Year 19 GO TO Q321 308. Do you and your partner ever use a condom in addition to the method you are using? 1 Yes 2 No 309. Where do you get your family planning method? 1 Regional/District Physician's office 2 Polyclinic physician's office 3 Hospital 4 Private practice physician 5 Pharmacy 6 Condom machine 7 At a store (not pharmacy) 8 Don't know 310. Do (Did) you pay for this method? 1 Yes 2 No 311. Would you prefer to use a different method of family planning from the one you are currently using? 1 Yes 2 No--->GO TO Q314 312. What method would you prefer to use? 1 Pills 2 IUD 3 Condoms 4 Foam/Jelly/Cream 5 Diaphragm 6 Female sterilization 7 Male sterilization 8 Fertile days method 9 Withdrawal 20 Other _______________ 77 Any method-- ----->GO TO Q314 88 Not sure --------->GO TO Q314 15 313. What is the most important reason that you do not use that method? 1 Doctor will not prescribe it 2 Cost 3 Not available 4 Too far away 5 Do not know how to obtain it 6 o it Husband objects t 7 Religious reasons 20 Other______________________ 88 Don't know 314. IF USIN YS METHOD(Q306=8, 9, OR 10) G WITHDRAWAL, RHYTHM, OR FERTILE DA CONTINUE WITH Q314; USERS OF OTHER METHODS GO TO Q316. You said that you are now using ____ to avoid becoming pregnant, rather than a method you might obtain from a doctor, health facility, or pharmacy. Please tell me whether each of the following was very important, somewhat important, or not important at all in your decision to use this method: Very Somewhat Not Not Important Important Important Sure A. Difficult to get other methods 1 2 3 8 B. Cost of other methods 1 2 3 8 C. Little knowledge of other methods 1 2 3 8 D. Health/Side effects other methods 1 2 3 8 E. Husband/Partner preference 1 2 3 8 F. Religious beliefs 1 2 3 8 315. How effective at preventing pregnancies do you think _ (method currently used) is compared to modern methods, like the pill or the IUD? (READ CHOICES) 1 Current method more effective 2 About equally effective 3 Current method less effective 8 Don't know/Not sure 316. Do you have any problems or concerns with using __________? 1 Yes 2 No--->GO TO Q318 317. What is the most important problem or concern? 1 Side effects 2 Health concerns 3 Access/Availability 4 Cost 5 Sometimes forget to use 6 Sometimes difficult/inconvenient to use 7 Husband/partner disapproves 20 Other __________________________ 318. Do you plan to have any (more) children? 1 Yes 2 No --- >GO TO Q321 8 Not sure -- >GO TO Q321 319. How many more do you plan to have? children 66=As many as possible 77=Up to God/Fate, etc. 88=Not sure 320. When do you think you would like to become pregnant? 1 Within 1 year 2 In 1-2 years 3 In 3-5 years 4 In more than 5 years 7 When I get married 8 Not sure/Don't know 321. Think back to when you first started using a method to prevent pregnancy. What method was it? 1 Pills 2 IUD 3 Condoms 4 Foam/Jelly/Cream 5 Diaphragm 6 Female sterilization 7 Male sterilization 8 Fertile days method 9 Withdrawal 20 Other_______________ 88 Don't remember 322. How many living children did you have at that time? children 8=8 or more 323. How old were you at that time? years 16 17 328. CONTRACEPTIVE USE/PREGNANCY CALENDAR: Starting at the beginning of 1988, please try to remember in which months you started and stopped use of contraceptive methods. (INTERVIEWER: FILL IN ALL PREGNANIES AND BIRTHS FROM PREGNANCY HISTORY BEFORE COLLECTING CONTRACEPTIVE HISTORY). COLUMN 1 CONTRACE PT/PREGNANCY 0 No method 1 Pills 2 IUD 3 Condoms 4 Vaginal method 5 Fertile days method 6 Withdrawal 7 Sterilization 8 Other ____________ 9 Don't remember 2 0 Pregnant 21 Live birth 22 Stillbirth 23 Miscarriage 24 Extrauterine preg 25 Induced abortion -------------------- COLUMN 2 REASON STOPPED USING 1 Pregnant on method 2 Wanted pregnancy 3 Husband objected 4 Side effects 5 Health concerns 6 Physician decision 7 Supply/Availabil. 8 Inconvenient meth 9 Infrequent sex 10 Couldn't get preg 11 Marriage ended 2 0 Other___________ 88 Don't remember DATE 1 2 DATE 1 2 1988 1991 Jan 1 Jan 1 Feb 2 Feb 2 Mar 3 Mar 3 Apr 4 Apr 4 May 5 May 5 Jun 6 Jun 6 Jul 7 Jul 7 Aug 8 Aug 8 Sep 9 Sep 9 Oct 10 Oct 10 Nov 11 Nov 11 Dec 12 Dec 12 1989 1992 Jan 1 Jan 1 Feb 2 Feb 2 Mar 3 Mar 3 Apr 4 Apr 4 May 5 May 5 Jun 6 Jun 6 Jul 7 Jul 7 Aug 8 Aug 8 Sep 9 Sep 9 Oct 10 Oct 10 Nov 11 Nov 11 Dec 12 Dec 12 1990 1993 Jan 1 Jan 1 Feb 2 Feb 2 Mar 3 Mar 3 Apr 4 Apr 4 May 5 May 5 Jun 6 Jun 6 Jul 7 Jul 7 Aug 8 Aug 8 Sep 9 Sep 9 Oct 10 Oct 10 Nov 11 Nov 11 Dec 12 Dec 12 IF NOT USING A METHOD IN JANUARY 1988 SKIP Q329 329. You said you were using ____ in January of 1987. When did you start using that method? Month Year 19 IF CURRENTLY USING A FAMILY PLANNING METHOD, GO TO Q338 18 330. Do you think you are able to get pregnant at the present time? 1 Yes--->GO TO Q332 2 No--- >GO TO Q331 3 Not sure--- >GO TO Q332 4 Currently pregnant-- >Q332 331. Why not? 1 Menopause/Too old to get pregnant \ 2 Has had an operation for medical reasons \ that makes pregnancy impossible \ 3 Husband/partner has had a medical operation \ 4 Has tried to get pregnant for \ - >GO TO Q345 at least 2 years without success / (or has not gotten pregnant despite / 2 years not contracepting) / 5 Doctor says she or partner is infertile / 6 Not sexually active ------------- >GO TO Q332 7 Postpartum/Breastfeeding -------- >GO TO Q332 8 Other (specify) _______________--->G0 TO Q332 332. Do you plan to have any (more) children (after this pregnancy)? 1 Yes 2 No---- >GO TO Q336 3 Not sure---- >GO TO Q336 333. How many more children do you plan to have? children 66=As many as possible 77=Up to God/Fate, etc. 88=Not sure IF CURRENTLY PREGNANT SKIP TO Q338 334. Are you trying to become pregnant now? 1 Yes--->GO TO Q337 2 No 335. When do you think you would like to become pregnant? 1 Within 1 year 2 In 1-2 years 3 In 3-5 years 4 In more than 5 years 7 When I get married 8 Not sure 19 336. What is the most important reason you are not using a method to avoid pregnancy now? 0 Currently pregnant ----->G0 TO Q3 38 1 Not sexually active/No partner------>G0 TO Q338 2 Want to become pregnant 3 Only occasionally sexually active 4 Breastfeeding/Postpartum 5 Fear of side effects/health effects 6 Previously had side effects/health problems 7 Husband/Partner objects 8 Religious reasons 9 Doctor won't prescribe method 10 Desired method not available/difficult to get 11 Too expensive 12 Don't know where to get method 13 Methods difficult to use 14 Prefer abortion 15 Haven't bothered, but would like to use method 16 Too old 17 Difficulty getting pregnant 20 Other (specify) ________________________________ 88 Don't know 337. Does your husband/partner think that you should be using a method to prevent you from becoming pregnant? 1 Yes 2 No 3 No husband/partner 8 Don't know 338. PLANS TO HAVE MORE CHILDREN 1 YES (Q318=l OR Q332=l) ------- >CONTINUE WITH Q341 2 NO (Q318=2 OR Q332=2) ------- >GO TO Q339 3 NOT SURE (Q318 = 8 OR Q332 = 3)- -->C0NTINUE WITH Q341 339. Are you interested in having an operation to prevent you from having any more children (after this pregnancy)? 1 Yes --- >GO TO Q341 2 No 3 Not sure --- >GO TO Q341 4 STERILIZED (Q306=6 OR 7) ----- >GO TO Q341 340. What is the most important reason you wouldn't be/are not interested? 1 Health risks 2 Fear of operation 3 Husband would object 4 Religious reasons 5 Not culturally/socially acceptable 6 Cost/inconvenience of an operation 7 Might want another child 8 Don't know enough about sterilization 9 Haven't thought about it 20 Other_______________________________ 88 Don't know 20 341. In the past five years have you ever unsuccessfully tried to get birth control pills? 1 Yes 2 No--->GO TO Q343 342. What was the reason you were unable to get them? 1 Physician refused because of health/side effects 2 Physician refused because of age 3 Physician refused because of marital status 4 Physician refused, other _____________________________ 5 Pills unavailable/out of stock 6 Cost 7 Other (specify) ______________________ 8 Don't remember 343. In the past five years have you ever unsuccessfully tried to get an IUD? 1 Yes 2 No---->G0 TO Q345 344. What was the reason you were unable to get it? 1 Physician refused because of health/side effects 2 Physician refused because of age 3 Physician refused because of marital status 4 Physician refused, other_____________________________ 5 IUDs unavailable/out of stock 6 Cost 7 Other (specify)_______________________ 8 Don't remember IF NEVER MARRIED, GO TO NEXT SECTION (Q400) 21 345. Have you (or your husband/partner) ever been to a doctor or clinic to talk about ways to help you become pregnant or to prevent a miscarriage? 1 Yes 2 No--->GO TO NEXT SECTION (Q400) 346. What kinds of medical treatment or advice did you or your husband/partner receive to help you become pregnant or prevent miscarriages? (READ ALTERNATIVES) YES NO PR A. Drugs to make you ovulate 1 2 8 B. Surgery or treatment for blocked tubes 1 2 8 C. Infertility tests on you 1 2 8 D. Advice on how to time intercourse 1 2 8 E. Advice to start or stop contraception 1 2 8 F. Tests on husband/partner 1 2 8 G. In vitro fertilization 1 2 8 H. Artificial insemination 1 2 8 I. Bed rest 1 2 8 J. Other (specify)___________________________ 1 2 8 347. When was the last time you or your husband/partner visited a doctor/clinic for this treatment or advice? Month Year 19 22 MATERNAL-CHILD HEALTH THE FOLLOWING QUESTIONS DEAL WITH THE MOST RECENT PREGNANCY THAT LED TO A LIVE BIRTH SINCE 1/88 IF NO LIVE BIRTHS SINCE 1/88, GO TO Q500 400. Which of the following best describes your reaction to your most recent pregnancy? (READ CHOICES) 1 Immediately happy about it 2 Accepted it easily and quickly became happy about it 3 Accepted it eventually 4 Was never able to accept it 5 Other (Specify) ______________________________ 401. Which of the following best describes the father's reaction to that pregnancy? (READ CHOICES) 1 Immediately happy about it 2 Accepted it easily and quickly became happy about it 3 Accepted it eventually 4 Was never able to accept it/Refused to become involved 5 Did not know about pregnancy 8 Don't know 402. Did your job during that pregnancy involve much physical work, a moderate amount, or only a little? 1 Much physical work 2 A moderate amount 3 Little or no physical work 4 Did not work------ >GO TO Q405 403. Did your job during that pregnancy involve much standing, a moderate amount of standing, or little standing? 1 Much standing 2 Moderate standing 3 Little standing 404. Would you say that job generally involved much, a moderate amount, or only a small amount of mental stress? 1 Much stress 2 Moderate stress 3 Little stress 405. Did you receive any prenatal care from a doctor, nurse, or midwife for that pregnancy? 1 Yes 2 No--->GO TO Q418 406. Who provided the most care? 1 Physician 2 Midwife/Nurse 3 Physician and midwife equally 407. How many months pregnant were you when you made your first prenatal visit? ___ months 23 408. How many prenatal visits did you make during that pregnancy? visits 66=As many as doctor/midwife/nurse said to have 77=Don't remember, but was definitely at least 10 88=Don't remember 409. Where did you receive your prenatal care? (READ ALL CHOICES) 1 District clinic 2 District clinic and hospital 3 Hospital only 4 Other (specify) __________________ 410. How many minutes did it take you, on average, to reach the place where you received the most prenatal care? minutes 00O=At home/At factory -- >GO TO Q413 888=Don't remember 411. How did you usually get to that place? 1 Walk 2 Bus/Metro 3 Private vehicle 4 Other (specify) __________________ 412. On average, how long did you have to wait to be seen? minutes 888=Don't remember 413. During that pregnancy did you have an ultrasound? 1 Yes 2 No--------------------------- >GO TO Q415 8 Don't know/Don't remember ---- >GO TO Q415 414. Did anyone (e.g., midwife, physician) explain to you or make sure you understood the purpose of this procedure? 1 Explained well 2 Explained only a little 3 Did not explain 8 Don't remember 415. During that pregnancy did you have an amniocentesis? 1 Yes 2 No --------- >GO TO Q418 8 Don't know - >GO TO Q418 416. During what month of pregnancy was it done? month 88=Don't know 24 417. Why was it done? (READ CHOICES) 1 To test for possible birth defect 2 For RH immunization 3 Metabolic disorder 4 Other ____________________________ 5 Don't know/Was not explained 8 Don't remember 418. During your last pregnancy did a doctor (or midwife?) ever tell you to remain in bed/stay off your feet for one or more weeks because of some problem related to your pregnancy? 1 Yes 2 No--->GO TO Q420 419. Altogether, how long did you stay in bed because of this problem during that pregnancy? weeks 01=1 week or less 420. During your last pregnancy were you ever hospitalized because of any problem related to your pregnancy? 1 Yes 2 No--->GO TO Q423 421. Altogether, how many days were you hospitalized because of this problem during that pregnancy? days 422. Were any of the following conditions the reason you were hospitalized? (READ EACH CONDITION) YES NO DK/DR A. Threatened miscarriage; bleeding 1 2 8 in first half of pregnancy B. Bleeding during second 1 2 8 half of pregnancy C. High blood pressure (hypertension) 1 2 8 before pregnancy D. High blood pressure (hypertension) 1 2 8 related to pregnancy E. Early or false labor 1 2 8 F. Swollen ankles, water retention, edema 1 2 8 G. Improper position of fetus 1 2 8 H. Previous cesarean section 1 2 8 I. Other (specify) ________________________ 1 2 8 423. Did you smoke cigarettes just before you became pregnant? 1 Yes 2 No--->GO TO Q426 25 424. Did you smoke cigarettes during that pregnancy? 1 Yes 2 No -->G0 TO Q426 425. About how many cigarettes did you smoke each day, on average, during t hat pregnancy? (ONE PACK=20 CIGARETTES) cigarettes 77=Less than 1 per day 80=80 or more 88=Don't remember 426. How many times per week did you drink alcoholic beverages during that pregnancy? 1 rAt least 4 times pe week 2 1-3 times per week 3 Less than once per week 4 Never 9 No response 427. How much did your last baby weigh when he/she was born? grams-->GO TO Q429 8888=Don't know/Don't remember-- >GO TO Q428 428. Do you remember if he/she weighed less than 2500 grams or was considered to be low birth weight? 1 (Yes <2500 grams/low birth weight) 2 No 8 Don't remember/Don't know 429. Was your last delivery normal or cesarean? 1 Normal 2 Cesarean 430. Would you rate the place in which you had your last delivery as good, fair, or poor in the following areas? GOOD FAIR POOR DK/DR A. Distance from home 1 2 3 8 B. Physical facilities 1 2 3 8 C. Crowdedness 1 2 3 8 D. Helpfulness/Attenti 1 2 3 8veness of staff E. Competence of staff 1 2 3 8 431. Would you say that your delivery was (READ CHOICES): 1 Shorter than you expected 2 About as long as you expected 3 Longer than you expected 4 Planned Cesarean section--->GO TO Q433 432. Would you say that your labor was (READ CHOICES): 1 Less painful than you expected 2 About as painful as you expected 3 More painful than you expected 26 433. Do you feel that you received enough information regarding your pregnancy from those providing your care? 1 Yes 2 No 434. Do you feel that you received enough information regarding what to expect during your labor and delivery from those providing your care? 1 Yes 2 No 435. Who would you have wanted to be present at your delivery?(READ CHOICES) 1 Your husband/partner 2 Your mother 3 __________________________ Other person (specify) __ 4 Only professional staff 436. If you were to have another child, would you be interested in delivering your baby at home, rather than in a hospital? 1 nYes, defi itely 2 Possibly 3 No, definitely 4 Not sure 437. If you were to have another child, do you think you would prefer to have it by cesarean section or normally? 1 Cesarean 2 Normal 3 Not sure 438. What was your biggest problem the first week after delivery? 1 Health/Care of the child 2 Breastfeeding 3 Her own health 4 Behavior of professional staff 5 Hospital environment 6 Visiting/Contact with family 7 Other (specify)______ _______________ 77 No important problems 88 Don't remember 439. What was your biggest problem when you returned

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