Engender Health- Contraceptive Sterilization: Chapter 2

Publication date: 2002

Chapter 2 Sterilization Incidence and Prevalence In 1985, Ross, Hong, and Huber concluded that overall use of contraceptive sterilizationhad been growing considerably worldwide over a number of years and showed no signs of decline anywhere. Here, we examine trends in new and continued use of sterilization that have taken place since 1985 and explore some of the factors that have produced these changes. Because of this chapter’s population-level focus, the analysis here will be limited primarily to the demographic factors affecting change. Programmatic, political, sociocul- tural, and technological factors affecting choice and use are discussed more fully in sub- sequent chapters. Information on the use of sterilization within a population is usually expressed in terms of incidence and prevalence. Sterilization incidence refers to the rate at which peo- ple in a given population begin to use sterilization, over a specified period of time (usu- ally one year), relative to the number of women aged 15–44 or 15–49 who were married or in union during that time period. In practical terms, it reflects the number of steril- ization procedures performed annually among people of reproductive age. Because it is difficult to obtain the accurate national-level service statistics needed to derive direct measures of sterilization incidence, we rely on surveys of women of reproductive age to estimate an approximate incidence measure.1 Within the context of sterilization, prevalence provides a “snapshot” of overall lev- els of sterilization use, measuring the number of people in a population using this 17 © 2002 EngenderHealth Highlights: • Approximately 222 million women of reproductive age around the world are protected from unin- tended pregnancy by sterilization—180 million using female sterilization and nearly 43 million re- lying on male sterilization. • The incidence of female sterilization (the number of sterilization procedures performed each year) is highest in Latin America and the Caribbean and is lowest in Eastern Europe, North Africa, and the Middle East. • The prevalence of female sterilization (the total number of people using the method at a particular point in time) is highest in Latin America and the Caribbean and in Asia. In contrast, the prevalence of male sterilization is highest in parts of Western Europe, in North America, and in Asia. • Most sterilization users live in Asia, with China and India accounting for 75% of the world’s total number of sterilization users. 1 In this chapter, we present a proxy measure of incidence derived from demographic surveys, as direct measures of incidence were not obtainable. For these analyses, sterilizations in the year are obtained among women ever in union, either by using questions about the respondent’s age at sterilization com- pared with her current age or by using the date of sterilization. Information on the number of new vasec- tomy users in the year is obtained from female partners who answered the survey. In general, the coun- tries reviewed in this chapter all had a total sterilization prevalence of at least 2%, as given in recent surveys. (Although this threshold is arbitrary, any percentage smaller than 2% would be statistically un- reliable for performing calculations of incidence.) From Contraceptive Sterilization: Global Issues and Trends, EngenderHealth 18 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS method at a given point in time. According to conventional practice, sterilization preva- lence is often presented as a percentage, with the number of sterilization users expressed relative to the number of women currently married or in union (Bertrand, Magnani, & Knowles, 1994), and is measured using data from surveys of women of reproductive age (generally aged 15–49). In countries where there is substantial use of vasectomy, the prevalence of sterilization among men is obtainable through women’s reports of their partner’s use of vasectomy. Any family planning method’s prevalence and incidence are linked, since “in the long run, the prevalence of any method is directly proportional to the annual acceptance rate (or incidence) and the mean continuation time” (Ross, 1992). Although prevalence is often used to compare levels of use across different contraceptive methods within a population, sterilization’s uniqueness as a permanent method warrants special consider- ation in this type of analysis. Unlike temporary methods, such as the pill or condom, that can be discontinued at any time, protection with sterilization continues throughout the reproductive years (except in the case of failure). As a result, the number of sterilization users grows over time. Women leave this “pool” of users only when they exceed repro- ductive age. The data presented in this chapter are derived primarily from the Demographic and Health Survey (DHS) and the U.S. Centers for Disease Control and Prevention (CDC) series of family planning and reproductive health surveys. Most are nationally repre- sentative household-based sample surveys. For North America, Oceania (Australia and New Zealand), and Western Europe, most data are derived from surveys conducted by agencies within the country. In general, these surveys tend to present information on contraceptive use as reported by women, though this practice is changing to include male interviews as well (e.g., in Bangladesh, Colombia, Kenya, Pakistan, and Tanza- nia). For this analysis, however, we present data as reported by women. Also, we include consecutive reproductive health surveys whenever possible, starting from 1985. The data presented for these multiple surveys are cross-sectional, as different sets of respon- dents were sampled and interviewed each time the survey was carried out. Global Status of Sterilization Worldwide, at least 222.4 million women in union currently use sterilization (whether tubal ligation or vasectomy) as their method of family planning. Supplements 2.1 and 2.2 (page 47) report the estimated numbers of sterilization users for different regions and countries. Two factors affect the number of users in a country: the overall population, and the prevalence of sterilization (Ross et al., 1985). In turn, sterilization prevalence is a product of sterilization incidence and the continuation time of the method. In this chapter, we look at global data on overall sterilization incidence and preva- lence, as well as the number of users since the 1980s. All three measures are broken down separately for female and male sterilization, when possible. In addition, we in- clude information on sterilization as a percentage of total contraceptive prevalence (use of both traditional and modern methods), to provide a context in which to consider ster- ilization’s contribution to overall contraceptive use. Incidence Recent data show that regions vary considerably in their sterilization incidence. Table 2.1 (page 20) summarizes the approximate average incidence of female and male steril- ization for selected countries with data available from the DHS or CDC surveys, calcu- lated over five-year periods.2 (Annual estimates are presented in Supplements 2.3 and 2.4, pages 52 and 54, respectively.) © 2002 EngenderHealth 2 U.S. data are derived from the National Survey of Fertility Growth (NSFG). Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 19 What accounts for changes in incidence? Demographic, policy, or program factors all can cause changes in the incidence of ster- ilization. Demographic factors that may influence sterilization incidence include changes in the age distribution, the percentage married or cohabiting, the average age at marriage, the average parity, and mean educational attainment. Policy factors that can influence incidence are illustrated historically in countries such as Bangladesh, India, and Sri Lanka, where sterilization incidence has fluctuated over the past three decades (Ross et al., 1985). Incidence in these countries dropped substantially in the late 1970s, at the end of an era of special national sterilization campaigns. For example, in India, changes in sterilization incidence coincided in the 1970s with government-led interventions to increase the sterilization acceptance rate through mas- sive recruitment campaigns and some coercion, and with the ebb and flow of payments made to new users. In India, sterilization incidence reached a high of 7% of all couples at the time of the 1976 Emergency Campaign and dropped to about 2% among married women five years later (Ross et al., 1985). This decline in sterilization incidence coin- cided with a governmental effort to remove method-specific contraceptive targets na- tionwide. This effort was followed by India’s approval, in 2000, of a national popula- tion policy articulating demographic goals but balancing the twin objectives of reducing fertility and promoting reproductive health, as was advocated in the Programme of Ac- tion adopted at the 1994 International Conference on Population and Development in Cairo (Pachauri, 2000). Changes in incidence may also correspond to shifts in demographics. As couples age or reach their desired family size, the incidence of sterilization may change year by year, growing sometimes more quickly and sometimes more slowly. In a number of Latin American countries, for example, both the number of couples reaching their re- productive years and the number seeking to limit their family size have increased greatly since the 1960s (Merrick, 1994); these factors may explain the growth in incidence of sterilization, particularly female sterilization. The influence of demographic factors on sterilization incidence is well illustrated in the case of China. China’s irregular age dis- tribution, influenced by famines and changes in the legally permissible marriage age, produced dramatic changes in the number of new users of sterilization over the past sev- eral decades (Ross & Frejka, 1998). Demographic and policy factors are generally considered to have less influence on incidence than program factors. Sterilization incidence fluctuates depending on the numbers of unsterilized couples in the relevant age-groups, which change from year to year. It can decline when the prevalence of use of other modern contraceptive methods is quite high, or when sterilization prevalence itself has risen to a high level (Ross & Pot- ter, 1980; Ross et al., 1985), as in countries such as India, Sri Lanka, and Thailand. Find- ings from a recent sterilization assessment in Bangladesh show that policy, program, and management factors all had an impact on the decline in sterilization incidence (Begum et al., 2000). A change in the method mix—i.e., in the range of modern contraceptive methods available to couples—can also influence the rate of acceptance of sterilization. For ex- ample, in many countries where the intrauterine device (IUD) has been made available and accessible, this long-acting method may have become a partial substitute for earlier sterilization. The IUD has played a significant role in some countries where sterilization has never caught on—for example, in many Middle Eastern countries, such as Egypt, Jordan, Syria, and Turkey. In Indonesia, Norplant implants have had the same effect. The injectable hormonal contraceptive Depo-Provera has also become a popular method, perhaps especially in countries where social acceptance of family planning may be limited, where clandestine use (i.e., women’s use of a method without their partner’s knowledge) is more prevalent, or where fertility preferences reinforce a high demand for reversible family planning methods. © 2002 EngenderHealth © 2002 EngenderHealth 20 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Table 2.1. Average five-year incidence of female and male sterilization per 100 women of reproductive age (15–49) who were ever in union, by selected countries, year, and source of data Country/year/source Female sterilization Male sterilization Bangladesh, 1987 (DHS) 2.2* 0.5 Bangladesh, 1993–1994 (DHS) 0.4 0.0 Bangladesh, 1996–1997 (DHS) 0.2 md Belize, 1991 (CDC)† 1.7 �0.1 Bolivia, 1989 (DHS) 0.4 0.0 Bolivia, 1993–1994 (DHS) 0.4 0.0 Bolivia, 1998 (DHS) 0.5 0.0 Brazil, 1986 (DHS)† 3.0 0.1 Brazil, 1991 (DHS)‡ 3.3 0.0 Brazil, 1996 (DHS) 2.5 0.3 Cape Verde, 1998 (CDC) 1.4 �0.1 Colombia, 1986 (DHS) 1.7 0.0 Colombia, 1990 (DHS) 1.7 0.1 Colombia, 1995 (DHS) 1.8 0.1 Costa Rica, 1993 (CDC) 1.6 �0.1 Dominican Republic, 1986 (DHS) 2.7 0.0 Dominican Republic, 1991 (DHS) 2.9 0.0 Dominican Republic, 1996 (DHS) 2.6 0.0 Ecuador, 1987 (DHS) 1.4 0.0 Ecuador, 1989 (CDC) 1.4 0.0 Ecuador, 1994 (CDC) 1.5 0.0 Ecuador, 1999 (CDC) 1.6 0.0 Egypt, 1988 (DHS) 0.1 0.0 Egypt, 1992 (DHS) 0.1 0.0 Egypt, 1995–1996 (DHS) 0.1 0.0 El Salvador, 1985 (DHS) 3.0 0.0 El Salvador, 1988 (CDC)† 2.5 0.0 El Salvador, 1993 (CDC) 2.0 0.0 El Salvador, 1998 (CDC) 1.9 0.0 Ghana, 1988 (DHS) 0.0 0.0 Ghana, 1993 (DHS) 0.1 0.0 Guatemala, 1987 (DHS)† 1.0 0.1 Guatemala, 1995 (DHS) 1.0 0.1 Honduras, 1996 (CDC) 1.5 0.0 India, 1992–1993 (DHS) 1.8 0.1 Indonesia, 1987 (DHS) 0.3 0.0 Indonesia, 1991 (DHS) 0.2 0.0 Indonesia, 1994 (DHS) 0.2 0.1 Indonesia, 1997 (DHS) 0.2 0.0 Jamaica, 1997 (CDC) 0.8 0.0 Jordan, 1990 (DHS)§ 0.5 0.0 Kenya, 1989 (DHS) 0.0 0.0 Kenya, 1993 (DHS) 0.7 0.0 Kenya, 1998 (DHS) 0.4 0.0 Mauritius, 1985 (CDC)� 0.5 0.0 Mauritius, 1991 (CDC)† 0.7 0.0 (cont’d.) © 2002 EngenderHealth Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 21 Mexico, 1987 (DHS) 1.9 0.1 Morocco, 1987 (DHS) 0.2 0.0 Morocco, 1992 (DHS) 0.2 0.0 Namibia, 1992 (DHS) 0.7 0.0 Nepal, 1996 (DHS) 1.0 0.4 Nicaragua, 1992–1993 (CDC) 1.6 0.0 Nicaragua, 1998 (DHS) 2.5 0.0 Panama, 1984 (CDC) 2.7 0.0 Paraguay, 1987 (CDC) 0.4 0.0 Paraguay, 1990 (DHS) 0.8 0.0 Paraguay, 1995–1996 (CDC) 0.5 0.0 Paraguay, 1998 (CDC) 0.9 0.0 Peru, 1986 (DHS) 0.5 0.0 Peru, 1991–1992 (DHS) 0.6 0.0 Peru, 1996 (DHS) 0.8 0.0 Philippines, 1993 (DHS) 0.7 0.0 Philippines, 1998 (DHS) 0.5 0.0 Puerto Rico, 1995–1996 (CDC) 2.4 md Romania, 1999 (CDC)† 0.1 0.0 Sri Lanka, 1987 (DHS) 2.2 0.5 Swaziland, 1988 (CDC) 0.4 md Tanzania, 1991–1992 (DHS) 0.3 0.0 Tanzania, 1996 (DHS) 0.2 0.0 Thailand, 1987 (DHS) 1.9 0.5 Trinidad and Tobago, 1987 (DHS) 0.8 0.0 Tunisia, 1988 (DHS) 1.1 0.0 Turkey, 1993 (DHS) 0.3 0.0 Ukraine, 1999 (CDC)† 0.1 0.0 United States, 1988 (NSFG) 8.4 md United States, 1995 (NSFG) 6.5 md Zambia, 1992 (DHS) 0.2 0.0 Zambia, 1996 (DHS) 0.2 0.0 Zimbabwe, 1988–1989 (DHS) 0.2 0.0 Zimbabwe, 1994 (DHS) 0.3 0.0 * Meaning 0.4 sterilizations per 100 ever-married women per year. † Data refer to ages 15–44. ‡ Data are limited to Northeastern Brazil. § Excludes the West Bank. � Data are not weighted. Notes: md�missing data. Data included here were generated at the request of EngenderHealth by Measure- DHS� and by the Division of Reproductive Health, CDC. Table 2.1. Average five-year incidence of female and male sterilization per 100 women of reproductive age (15–49) who were ever in union, by selected countries, year, and source of data (cont’d.) Country/year/source Female sterilization Male sterilization 22 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Incidence of female sterilization Sterilization users (both new and continuing) are still overwhelmingly female (Ross, Hong, & Huber, 1985). (Chapters 1 and 5 explore some of the supply and demand issues that may explain the more widespread use and greater acceptance of female sterilization.) As shown in Table 2.1, the highest average incidence rates are found in Latin Amer- ica and Caribbean, where female sterilization has been the leading family planning method for decades. Brazil, the Dominican Republic, Nicaragua, Panama, and Puerto Rico all have female sterilization acceptance rates of 2–3% per year. Incidence is also high in El Salvador and Mexico (1.9%) and moderately high in several other Latin American countries. In these countries, interest in female sterilization is high, as is the availability of the method, thus contributing to relatively high incidence rates. Over time, no trend is identifiable in the region’s overall average incidence of fe- male sterilization (Figure 2.1). Despite fluctuations, the rate in the Dominican Republic remained above 2.5%. Incidence still is fairly stable in Guatemala and has increased minimally in Colombia. In this region, the most dramatic changes have taken place in Nicaragua, where average rates have risen from 1.6% to 2.5%, and in El Salvador, where average incidence has declined steadily since 1985 (from 3.0% to 1.9%). The approximate five-year average incidence of female sterilization in the United States, however, surpasses even rates found in Latin America and the Caribbean (Table 2.1). Although the U.S. rate has decreased since around 1988 (when it averaged 8.4% over a five-year period), the average 1995 rate of 6.5%3 is higher than that of any other country. As in Latin America, the wide availability and historical popularity of female sterilization explain its high incidence in the United States. Current incidence levels for parts of Asia and for Australia, Canada, and Western Europe are largely unavailable, but demographics, past history, and current prevalence levels (Supplement 2.5, page 55) suggest that Australia and many Western European countries may also have modest-to-high incidence levels of female sterilization (1–3%). For selected Asian countries for which data were available, Figure 2.2 suggests that in- cidence rates are falling in Bangladesh, Indonesia, and the Philippines. In contrast to countries with moderate-to-high incidence of female sterilization, countries in Eastern Europe, the Middle East, and North Africa tend to have incidence rates of 0.5% or less. Historically, use of female sterilization has been rare in these re- gions because of the lack of available services, coupled in some cases with religious © 2002 EngenderHealth Pe r 1, 00 0 wo m e n 30 20 10 0 Year 1985 1989 1993 1997 El Salvador Colombia Dominican Republic Nicaragua Guatemala 40 Figure 2.1. Five-year average incidence of female sterilization per 1,000 women of reproductive age who were ever in union, selected Latin American countries, 1985–1998 3 Data are from a special analysis by Anjani Chandra of 1995 NSFG data, National Center for Health Sta- tistics, 2000. Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 23 opposition to or legal restrictions on sterilization. In the Middle East and North Africa, only Jordan and Tunisia have estimated incidence rates of 0.5% or higher. In Central Asia and Eastern Europe, sterilization is much more rare than in neighboring countries to the west, but incidence is at measurable levels in Romania and Ukraine (0.1%). Similarly, until relatively recently, few countries in Sub-Saharan Africa have made use of female sterilization. Incidence is highest in Cape Verde (1.4%), Mauritius (0.7%), Kenya and Swaziland (0.4%), Zimbabwe (0.3%), and Tanzania and Zambia (0.2%). Time trends indicate that over a five-year period, the average annual incidence has re- mained stable or has even decreased. Figure 2.3 presents trend data for four selected North African and Sub-Saharan African countries. Estimated annual incidence rates in Egypt, Morocco, and Tanzania have remained steady over a 10-year period, while Kenya had a large increase between 1989 and 1993 and then saw incidence level off. The increase in Kenya is attributable to program factors, mainly the introduction of minilaparotomy (Church & Geller, 1990). Despite the low incidence of female steril- ization in Sub-Saharan Africa, sterilization prevalence is projected to rise in coming years in many of these countries (see Chapter 8), in part because of the future demo- graphic momentum of the younger populations in Africa. © 2002 EngenderHealth Pe r 1, 00 0 wo m e n 30 20 10 0 Year 1985 1989 1993 1997 Bangladesh Philippines Indonesia 40 Figure 2.2. Five-year average incidence of female sterilization per 1,000 women of reproductive age who were ever in union, selected Asian countries, 1985–1999 Pe r 1, 00 0 wo m e n 30 20 10 0 Year 1985 1989 1993 1997 Egypt Kenya Tanzania Morocco 40 Figure 2.3. Five-year average incidence of female sterilization per 1,000 women of reproductive age who were ever in union, selected North African and Sub- Saharan African countries, 1985 –1998 24 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Incidence of male sterilization Data on the incidence of vasectomy are difficult to obtain, as vasectomy is neither widely available nor commonly used in many countries. However, while sterilization use is greatly weighted toward female sterilization, Ross, Hong, and Huber (1985) noted that “there are significant breaks in the pattern.” Data for the past 15–20 years reveal that in some countries male sterilization contributes to overall prevalence and incidence lev- els for sterilization and represents an important family planning method. As shown in Figure 2.4, moderately high estimates of vasectomy incidence are seen in Sri Lanka and Thailand (5 per 1,000 each) over the five years prior to 1987. These countries have a fairly well-developed family planning and sterilization program that in- cludes vasectomy. In contrast, incidence in India remains low but measurable, at an es- timated five-year average of 1 per 1,000 in 1992–1993. Acceptance of vasectomy has been less in Latin America: Brazil has the highest incidence in the region, an average of 3 per 1,000 for the five years prior to the most recent survey; Colombia, Guatemala, and Mexico average 1 per 1,000. Worldwide, little change has occurred over time in the av- erage rate of vasectomy (Supplement 2.4), although in Bangladesh five-year incidence levels declined substantially. Although vasectomy incidence data for China and the Republic of Korea were not available for this review, these countries have the highest vasectomy prevalence rates in Asia, and it is likely that vasectomy incidence is similarly high. Incidence data for Hong Kong also were not available, but prevalence data (Supplement 2.2) suggest that vasec- tomy is also popular there. In the United States, estimates for 1991 and 1995 show vasectomy incidence to be rel- atively stable at 1.0% (or 10 per 1,000 men aged 25–49) (Magnani et al., 1999). In Canada, New Zealand, and the United Kingdom, where male sterilization’s prevalence is quite high relative to other developed countries, vasectomy incidence is also likely to be very high. Prevalence Patterns of sterilization prevalence are similar to those of incidence. However, as noted earlier, data on prevalence represent the cumulative number of sterilization users, as a © 2002 EngenderHealth Co un tri es a nd y e a rs Per 1,000 women Thailand, 1987 Sri Lanka, 1987 Brazil, 1996 Mexico, 1987 India, 1992–1993 Guatemala, 1995 Colombia, 1995 0 4 62 8 10 Figure 2.4. Five-year average incidence of male sterilization per 1,000 women of reproductive age who were ever in union, selected countries and years Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 25 proportion of the population of reproductive age currently in union. (Because these data are easier to obtain than are incidence data, we are able to present prevalence informa- tion for a much larger number of countries.) The most recent data on the prevalence of sterilization (both female and male) show that levels are highest in Asia, Latin America and the Caribbean, North America, Ocea- nia, and selected countries in Western Europe (Supplement 2.5). Where sterilization prevalence is relatively high, between one-fourth and one-half of all couples use the method. The countries and territories where the prevalence of female and male steril- ization is highest (Table 2.2) include Puerto Rico (49%), the Republic of Korea (47%), Canada and China (46%), Brazil (43%), the Dominican Republic (41%), the United States (39%), Australia (38%), Panama (34%), and New Zealand (33%). In much of Africa and the Middle East and in parts of Eastern Europe, the preva- lence of both female and male sterilization is far lower (less than 2%). The biggest ex- ception is South Africa (at 18%). In addition, nations such as Botswana, Cape Verde, Kenya, Mauritius, Namibia, and Swaziland now have sterilization prevalence rates of 5% or higher. The introduction of minilaparotomy services into family planning pro- grams in Sub-Saharan Africa may account for some of this increase in use (Church & Geller, 1990). Four factors that affect prevalence are age at sterilization, the historical availability of sterilization in a country, incidence rates, and continuation (Ross, 1992; Rutenberg & Landry, 1993). Many countries with high prevalence are generally characterized as hav- ing more established sterilization programs (Rutenberg & Landry, 1993). In compari- son, those with lower prevalence—for example, countries in Africa, Eastern Europe, © 2002 EngenderHealth Table 2.2. Twenty countries with the highest total sterilization prevalence (female and male) among women who are married or in union, by country and year of survey Country/date Prevalence (%) Puerto Rico, 1995–1996 48.7 Korea, Republic of, 1991 47.3 China, 1992 46.1 Canada, 1995 46.0 Brazil, 1996 42.7 Dominican Republic, 1996 41.0 United States, 1995 38.7 Australia, 1986 38.1 Panama, 1984 33.5 New Zealand, 1995 33.0 El Salvador, 1998 32.4 United Kingdom, 1993 32.0 India, 1992–1993 30.7 Mexico, 1995 27.3 Sri Lanka, 1993 27.2 Nicaragua, 1998 26.6 Colombia, 1995 26.4 Hong Kong, 1987 23.8 Thailand, 1993 22.6 Ecuador, 1999 22.5 26 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS and the Middle East—tend to have newer programs, and legal restrictions may bar es- tablishment of formal sterilization programs (see Chapter 4). Another factor that may result in differences in prevalence is age at sterilization. In much of Latin America, women who choose sterilization do so at younger ages than women in Africa (see Chapter 3). As noted above, Asia and Latin America are also re- gions with comparatively high sterilization incidence, which contributes to high preva- lence. Lastly, methodologies used in designing surveys in developed and developing countries may also influence reported rates; surveys conducted in developing countries tend to include women aged 45–49, whereas in developed countries the upper cutoff is usually set at age 44 (UN Population Division, 1999). In 1985, Ross, Huber, and Hong examined survey data on sterilization for a previ- ous 10-year period and reported a “rapid, historic, and unprecedented movement toward permanent contraception, in a diversity of settings.” They identified Asia and Latin America as regions with high levels of sterilization prevalence. Puerto Rico and the United States had the highest levels (46% and 39%, respectively, including hysterec- tomies), followed by Panama (30%), the Republic of Korea (28%), China (25%), and Thailand (23%). Costa Rica, the Dominican Republic, El Salvador, Hong Kong, India, Singapore, Sri Lanka, and Taiwan had high rates, ranging from 18% to 22%. In West- ern Europe, the highest levels of sterilization prevalence stood at 20% in the Netherlands and 16% in England and Wales combined. Many regional patterns noted in 1985 have remained the same. Asia, Latin Amer- ica, and parts of North America and Western Europe still have some of the highest prevalence. In fact, since 1985, sterilization prevalence has continued to grow in many of the countries (Figure 2.5). The largest increases have taken place in Brazil and the Do- minican Republic. In these countries, as well as in Colombia, Mexico, and Nicaragua, prevalence has increased by at least eight percentage points within a 10-year period. For the most part, these five countries are characterized by high acceptance rates and young age at sterilization (less than 30), which may contribute to these changes. Rates have also increased in China, where prevalence now stands at 46%. High acceptance rates (in China’s case, a product of its one-child policy) and decreasing age at sterilization in most of these countries may explain these trends. © 2002 EngenderHealth Year Pe rc e n t 50 40 30 20 10 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 North America and Western Europe Canada Finland France Netherlands United Kingdom United States Figure 2.5. Total prevalence of sterilization among women of reproductive age who were ever in union, selected countries, 1978–1999 (cont’d.) © 2002 EngenderHealth Year Pe rc e n t 20 16 12 8 4 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 Eastern and Southern Africa Botswana Kenya Malawi South Africa Tanzania Uganda Zimbabwe Year Pe rc e n t 20 16 12 8 4 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 Western Africa Cameroon Ghana Nigeria Senegal Togo Algeria Egypt Jordan Morocco Tunisia Turkey Yemen Year Pe rc e n t 20 16 12 8 4 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 North Africa and the Middle East Figure 2.5. Total prevalence of sterilization among women of reproductive age who were ever in union, selected countries, 1978–1999 (cont’d.) (cont’d.) Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 27 © 2002 EngenderHealth 28 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Bolivia Brazil Colombia Ecuador Paraguay Peru Year Pe rc e n t 50 40 30 20 10 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 South America Dominican Republic El Salvador Guatemala Honduras Jamaica Mexico Year Pe rc e n t 50 40 30 20 10 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 Central America and the Caribbean Figure 2.5. Total prevalence of sterilization among women of reproductive age who were ever in union, selected countries, 1978–1999 (cont’d.) (cont’d.) Smaller increases can be observed in a number of North African and Sub-Saharan African nations: In Kenya, Malawi, Mauritius, Morocco, Namibia, Tunisia, and Uganda, increases ranged from 0.5 to five percentage points between about 1985 and 1998. Lower acceptance of sterilization, older age at sterilization, and less-established programs are some characteristics associated with lower sterilization use in many of these countries. Sterilization prevalence has also decreased in a number of countries. The largest oc- curred in Japan (about six percentage points) over an eight-year period. Low acceptance, brought on by restrictive policies for sterilization, high reliance on abortion, high re- Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 29 liance on condoms, and an aging population may explain low and declining sterilization prevalence in Japan (Turner, 1993). Slight decreases (of 1–2 percentage points) in total sterilization prevalence have taken place in Jamaica, the Philippines, and Sri Lanka. Such decreases suggest that couples are using sterilization less and other family plan- ning methods more. Declines have also been noted in Finland (0.4 percentage points) and in France (3.8 percentage points). In Bangladesh, Ghana, and the Philippines, ster- ilization prevalence has fluctuated, in some cases falling back to levels that are similar to or slightly higher than those of the early 1980s. In Bangladesh, a rise in overall con- traceptive prevalence relative to the decrease in sterilization prevalence suggests greater use of alternative family planning methods. After sterilization prevalence increased sharply in India, as a result of aggressive governmental campaigns (from 21% to 31% over a six-year period), it has now settled at roughly 31%. © 2002 EngenderHealth Bangladesh India Nepal Pakistan Sri Lanka Year Pe rc e n t 30 20 10 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 South Asia 40 China Indonesia Japan Korea, Republic of Philippines Thailand Vietnam Year Pe rc e n t 50 40 30 20 10 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 Southeast Asia Figure 2.5. Total prevalence of sterilization among women of reproductive age who were ever in union, selected countries, 1978–1999 (cont’d.) 30 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Prevalence of female sterilization The prevalence of female sterilization is highest in Latin America and parts of Asia. Puerto Rico, the Dominican Republic, and Brazil have the highest rates anywhere, at 45%, 41%, and 40%, respectively (Table 2.3). Moreover, because the prevalence of male sterilization is extremely low in these countries, their high levels of overall steril- ization prevalence are usually a direct product of high levels of female sterilization. High acceptance rates, a comparatively low age at sterilization, and the broad availabil- ity of services all contribute to the high prevalence of female sterilization. These factors tend to be less common in parts of Africa, Eastern Europe, and the Middle East, where sterilization prevalence is lower. Other countries with comparatively high levels of fe- male sterilization include China (36%), the Republic of Korea (35%), Panama (33%), and El Salvador (32%). (No recent information is available on the prevalence of female sterilization in Mexico; however, given relatively high past levels of sterilization and overall low use of vasectomy, we infer that female sterilization prevalence is higher than 25% there.) Because female sterilization contributes greatly to overall sterilization prevalence in many countries, it mirrors many of the changes that have occurred in overall preva- lence. For example, female sterilization has grown mostly in China and Latin America, with smaller increases noted throughout Africa. Use of female sterilization has increased in Australia, Belgium, New Zealand, Norway, and the United States, often by 5–10 per- centage points; however, compared with trends in Latin America, these increases have occurred less rapidly. In their review of sterilization data in Scotland, Hunt and Annan- © 2002 EngenderHealth Table 2.3. Twenty countries with the highest prevalence of female sterilization among women who are married or in union, by country and year of survey Country/date Prevalence (%) Puerto Rico, 1995 –1996 45.2 Dominican Republic, 1996 40.9 Brazil, 1996 40.1 China, 1992 35.9 Korea, Republic of, 1991 35.3 Panama, 1984 33.1 El Salvador, 1998 32.4 Canada, 1995 29.8 Australia, 1986 27.7 India, 1992–1993 27.3 Mexico, 1995* 27.3 Nicaragua, 1998 26.1 Colombia, 1995 25.7 United States, 1995 23.8 Sri Lanka, 1993 23.5 Hong Kong, 1987 22.9 Ecuador, 1999 22.5 Cuba, 1987 22.0 Costa Rica, 1993 20.0 Thailand, 1993 19.8 * Prevalence data are not available by type of sterilization (male vs. female). We assume that the prevalence of male sterilization is 1% or less. Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 31 dale (1990) speculated that concern over hormonal methods, coupled with a low toler- ance for contraceptive failure and prior unsatisfactory experiences with contraceptive methods, led to higher acceptance and use of sterilization. The same may be true in some other developed countries. Decreases in the prevalence of female sterilization have also been observed in a few other countries, such as in Bangladesh, France, India, Japan, the Republic of Korea, and Thailand. Reasons for these changes may include greater interest in alternative methods (in Bangladesh, the Republic of Korea, and Thailand), changes in government policies or incentive programs (Bangladesh and India), and aging populations (France and Japan). Prevalence of male sterilization The prevalence of male sterilization is highest in parts of Asia, North America, Ocea- nia, and Western Europe. Specifically, Canada, New Zealand, the United Kingdom, and the United States have the highest rates, ranging from about 15% to 18% (Table 2.4). China and the Republic of Korea have the highest levels in Asia, at 10% and 12%, re- spectively. Most of these countries are characterized as having well developed steriliza- tion programs, including programs for vasectomy. In much of Africa, Eastern Europe, and Latin America, male sterilization rarely exceeds 1%. Figure 2.6 (page 33) illustrates that the level of male sterilization is lower than that of female sterilization in all countries except the United Kingdom (18% vs. 14%), the Netherlands (9% vs. 4%), Bhutan (8% vs. 3%), and New Zealand (18% vs. 15%). Ross et al. (1985) suggest that the improved surgical technology of the female sterilization procedure and the lack of institutional motivation to establish programs for men explain © 2002 EngenderHealth Table 2.4. Twenty countries with the highest prevalence of male sterilization among women who are married or in union, by country and year of survey Country/date Prevalence (%) New Zealand, 1995 18.0 United Kingdom, 1993 18.0 Canada, 1995 16.2 United States, 1995 14.9 Korea, Republic of, 1991 12.0 Australia, 1986 10.4 China, 1992 10.2 Netherlands, 1993 9.0 Switzerland, 1995 8.3 Bhutan, 1994 8.0 Nepal, 1996 5.4 Denmark, 1988 5.0 Norway, 1988–1989 4.3 Sri Lanka, 1993 3.7 Puerto Rico, 1995 –1996 3.5 India, 1992 –1993 3.4 Thailand, 1993 2.8 Brazil, 1996 2.6 Guatemala, 1995 1.5 Bangladesh, 1996 –1997 1.1 32 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS low acceptance rates for vasectomy. In addition, gender differences in sterilization prevalence may also be attributed to antipathy and poor information about vasectomy. (Further discussions of these factors can be found in Chapters 1 and 5.) Since the late 1970s and early 1980s, male sterilization prevalence has grown in Belgium, Canada, China, Norway, the Republic of Korea, and the United States.4 Minor fluctuations also have been noted in much of Asia. Use of male sterilization has also increased, albeit by smaller increments, in coun- tries such as Brazil, Colombia, and Guatemala. Educational and mass media promo- tional campaigns in these and other countries have established the existence of a market for vasectomy (Atkins & Jezowski, 1983; Liskin, Benoit, & Blackburn, 1992; Lynam et al., 1993; Vernon, 1996). Experience has shown that where providers and the media have promoted vasectomy and where quality services are made available, clients are drawn to services and use increases (Bertrand et al., 1987; Haws et al., 1997; Kincaid et al., 1996; Kiragu et al., 1995; Landry & Ward, 1997; Muhondwa & Rutenberg, 1997). In addition, overall numbers have been low in most areas because of what are termed “provider determinants,” such as the reluctance of national programs to establish wide- spread male services and to publicize them adequately (Kiragu et al., 1995; Ross et al., 1985), and the negative attitudes of individual providers toward vasectomy provision (Landry & Ward, 1997; Wilkinson et al., 1996). Current Numbers of Users Most of the world’s sterilization users are found in Asia (Figure 2.7, page 34), particu- larly China and India. Combined, China and India account for nearly 75% of the world’s total users (not shown). In comparison, Africa and the Middle East have about 2.2 mil- lion and 1.5 million sterilization users, respectively, or 1.6% of all users worldwide. Supplement 2.2 lists the number of sterilization users by country. It should come as no surprise that China and India account for the highest number of sterilization users: Both countries have large overall populations and relatively high sterilization prevalence (46% and 31%, respectively), producing a powerful combined effect on the numbers of users (Table 2.5, page 34). Countries and territories such as the Republic of Korea and Puerto Rico have higher total prevalence levels (47% and 49%, respectively) than China and India, but the overall number of women in union in these areas is considerably lower. As a result, the numbers of sterilization users in both represent little more than 2% of the worldwide estimate. In Africa and the Near East, the small number of sterilization users can be attributed primarily to the low prevalence of sterilization. With few exceptions, the number of sterilization users has increased across coun- tries since the 1985 review. Such increases have been especially marked in Brazil, China, and Colombia, where the number of current users is about six, three, and four times greater, respectively, than levels noted in the 1980s; in general, increases in other countries have been relatively less sizable. As previously mentioned, the rising preva- lence of sterilization may account in part for these increases, but the overall populations of these countries also appear to have grown considerably, with an ever more youthful population structure (Merrick, 1994). In comparison, decreases have been noted in a few countries in Africa (Côte d’Ivoire and Ghana) and Europe (Denmark and France). Number of female sterilization users In general, users of female sterilization outnumber users of male sterilization. World- wide totals show approximately 180 million female sterilization users and almost 43 © 2002 EngenderHealth 4 In these six countries, vasectomy prevalence prior to 1985 was 0.0% in Belgium (1976), 8.7% in Canada (1984), 6.9% in China (1982), 1.7% in Norway (1977), 5.2% in the Republic of Korea (1982), and 10.4% in the United States (1982) (Ross et al., 1985). © 2002 EngenderHealth Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 33 Percent 0 5 10 15 20 25 30 35 40 45 50 Norway, 1988–1989 Puerto Rico, 1995–1996 Sri Lanka, 1993 Switzerland, 1995 Thailand, 1993 United Kingdom, 1993 United States, 1995 Co un tri es a nd y e a r Denmark, 1988 Guatemala, 1995 India, 1992–1993 Korea, Republic of, 1991 Nepal, 1996 Netherlands, 1993 New Zealand, 1995 Australia, 1986 Belgium, 1991 Bhutan, 1994 Brazil, 1996 Canada, 1995 China, 1992 Colombia, 1995 Female sterilization Male sterilization Figure 2.6. Prevalence of female sterilization and male sterilization, selected countries, 1986 –1996 million male sterilization users, a ratio of about four to one. Asia has the most users of female sterilization (147 million, or 82% of the world’s total); most are concentrated in China (86 million) and India (48 million). Latin America and the Caribbean has the sec- ond-highest number of female sterilization users (about 15 million), followed by North America (excluding Mexico) and Western Europe combined, with 13 million; these two regions represent about 8% and 7% of the world’s total, respectively. © 2002 EngenderHealth 34 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Middle East 0.7% Africa 1.0% Latin America and the Caribbean 7.2% North America and Western Europe 9.6% Eastern Europe and Central Asia 0.2% Oceania 0.6% Asia 80.8% Figure 2.7. Percentage distribution of sterilization users, by region Table 2.5. Twenty countries with the highest total prevalence of sterilization and 20 countries with the highest total number of sterilization users, by country and year of survey Prevalence % Users No. (in millions)* Puerto Rico, 1995 –1996 48.7 China, 1992 110.13 Korea, Republic of, 1991 47.3 India, 1992–1993 54.49 China, 1992 46.1 United States, 1995 14.44 Canada, 1995 46.0 Brazil, 1996 11.44 Brazil, 1996 42.7 Korea, Republic of, 1991 3.78 Dominican Republic, 1996 41.0 United Kingdom, 1993 2.98 United States, 1995 38.7 Thailand, 1993 2.24 Australia, 1986 38.1 Canada, 1995 2.12 Panama, 1984 33.5 Bangladesh, 1996 –1997 1.94 New Zealand, 1995 33.0 Colombia, 1995 1.37 El Salvador, 1998 32.4 Indonesia, 1997 1.19 United Kingdom, 1993 32.0 Philippines, 1998 1.11 India, 1992–1993 30.7 Pakistan, 1994 –1995 1.07 Mexico, 1995 27.3 Australia, 1986 1.03 Sri Lanka, 1993 27.2 Iran, 1992 0.95 Nicaragua, 1998 26.6 South Africa, 1998 0.86 Colombia, 1995 26.4 Sri Lanka, 1993 0.79 Hong Kong, 1987 23.8 Vietnam, 1997 0.78 Thailand, 1993 22.6 Japan, 1994 0.75 Ecuador, 1999 22.5 Nepal, 1996 0.70 * Number of users is calculated by multiplying sterilization prevalence (obtained through reproductive health sur- veys) by the number of women in union (obtained from United Nations surveys). Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 35 Number of male sterilization users With regard to numbers, male sterilization users appear to be concentrated in Asia, North America, Oceania, and Western Europe. Because of the many vasectomy users in China (24 million), Asia accounts for 77% of all male sterilization users worldwide. Combined, North America, Oceania, and Western Europe contribute about 20% of va- sectomy users. Sterilization’s Share of Contraceptive Prevalence Supplement 2.5 displays information on sterilization as a percentage of all contraceptive prevalence. This measure represents the degree to which permanent methods contribute to all family planning use in a country. Table 2.6 summarizes the different scenarios that have occurred with regard to this percentage, with some country examples. In developing countries, longer-acting and highly effective clinic methods, such as female sterilization and the IUD, generally account for much of the method mix, a pat- tern very unlike that seen in more developed areas (UN Population Division, 1999). Where total contraceptive use is high but sterilization prevalence is low, steriliza- tion’s share of the total is low (Table 2.6), showing that most people rely on family plan- ning methods besides vasectomy and female sterilization. In France, for instance, con- traceptive prevalence is 75%, but sterilization represents only a fraction of that total prevalence level, because most users rely instead on oral contraceptives (de Guilbert- Lantoine & Leridon, 1998). In comparison, contraceptive users in countries such as Brazil and the Dominican Republic rely heavily on sterilization. In these countries, contraceptive prevalence is high (50% to 75%), and sterilization represents anywhere from 50% to 64% of the total. Where the sterilization percentage is high but the total is low, what little contraceptive use exists clearly consists mainly of sterilization. Bhutan, Guatemala, and Nepal are ex- amples of countries in which overall contraceptive prevalence is comparatively low (less than 30%), but sterilization’s share of prevalence is relatively high. The lack of availability of alternative methods and method preference are two factors that help ex- plain this scenario. References Atkins, B. S., and Jezowski, T. W. 1983. Report on the First International Conference on Vasec- tomy. Studies in Family Planning 14(3):89–95. Begum, F., et al. 2000. Review of sterilization services in Bangladesh. Dhaka: AVSC Interna- tional. © 2002 EngenderHealth Table 2.6. Relationship between levels of contraceptive prevalence and sterilization prevalence, and country examples Sterilization prevalence as a Contraceptive Sterilization % of contraceptive Country prevalence prevalence prevalence examples Low Low Low Bolivia, Uganda Low High High Guatemala, Nepal High Low Low France, Vietnam High High High Brazil, Dominican Republic 36 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Bertrand, J., et al. 1987. Evaluation of a communications program to increase adoption of vasec- tomy in Guatemala. Studies in Family Planning 18(6):361–370. Bertrand, J. T., Magnani, R. J., and Knowles, J. C. 1994. Handbook of indicators for family plan- ning program evaluation. Chapel Hill, NC: University of North Carolina at Chapel Hill, Carolina Population Center, Evaluation Project. Church, C. A., and Geller, J. S. 1990. Voluntary female sterilization: Number one and growing. Population Reports, series C, no. 10. Baltimore: Johns Hopkins University School of Pub- lic Health, Population Information Program. de Guilbert-Lantoine, C., and Leridon, H. 1998. Contraception in France: A balance-sheet after 30 years of liberalization. Population 53(4):785–811. Haws, J., et al. 1997. Increasing the availability of vasectomy in public-sector clinics. Family Planning Perspectives 29(4):185–186, 190. Hunt, K., and Annandale, E. 1990. Predicting contraceptive method usage among women in West Scotland. Journal of Biosocial Science 22(4):405–421. Kincaid, D., et al. 1996. Impact of a mass media vasectomy promotion campaign in Brazil. Inter- national Family Planning Perspectives 22(4):169–175. Kiragu, K., et al. 1995. The vasectomy promotion project (Kenya): Evaluation results. Baltimore: Johns Hopkins University Population Communication Project Working Paper. Landry, E., and Ward, V. 1997. Perspectives from couples on the vasectomy decision: A six-coun- try study. 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Calverton, MD. © 2002 EngenderHealth Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 41 Puerto Rico CDC. 1998. Puerto Rico Encuesta de Salud Reproductiva 1995–1996. Atlanta. Trinidad and Tobago Family Planning Association and Institute for Resource Development/Westinghouse. 1988. Trinidad and Tobago Demographic and Health Survey 1987. Port of Spain, pp. 18, 31. Middle East and North Africa Algeria Office Nationale des Statistiques. 1994. Algeria Maternal and Child Health Survey. Studies in Family Planning 25(3):191–195. Egypt Sayed, H. A. A. H., El-Khorazaty, M. N., and Way, A. A. 1985. Fertility and family planning in Egypt, 1984. Cairo: Egypt National Population Council and Westinghouse Public Applied Systems, pp. 155–156 (Table 9.4). National Population Council and Macro Systems. 1989. Egypt Demographic and Health Survey 1988. Cairo, p. 95 (Table 6). National Population Council and Macro International. 1993. Egypt Demographic and Health Sur- vey 1992: Preliminary report. Calverton, MD. National Population Council and Macro International. 1996. Egypt Demographic and Health Sur- vey 1995. Calverton, MD. Jordan Warren, C., Morris, L., and Higari, F. 1987. Jordan Husbands’ Fertility Survey 1985: Report of principal findings. Amman: Department of Statistics; and Atlanta: CDC, Table 7-6. Department of Statistics, Ministry of Health, and Macro International. 1991. Jordan Population and Family Health Survey 1990. Calverton, MD. Department of Statistics and Macro International. 1998. Jordan Population and Family Health Survey 1997. Calverton, MD. Kuwait al Rashoud, R., and Farid, S. (eds.) 1991. Kuwait Child Health Survey 1987. Al Kuwait: State of Kuwait Ministry of Health. Morocco Azelmat, M., Ayad, M., and Belhachmi, H. 1989. Enquête Nationale sur la Planification Famil- iale, la Fécondité et la Santé de la Population au Maroc 1987. Rabat, Morocco: Ministère de la Santé Publique and Institute for Resource Development/Westinghouse, p. 50. Ministère de la Santé Publique and Macro International. 1993. Maroc Enquête Nationale sur la Population et la Santé 1992. Calverton, MD. Ministère de la Santé Publique and Macro International. 1996. Maroc Enquête de Panel sur la Population et la Santé 1995. Calverton, MD. Oman Suleiman, M. J., Al-Ghassany, A., and Farid, S. (eds.) 1992. Oman Child Health Survey 1988. Muscat, Oman: Ministry of Health. Tunisia Office Nationale de la Famille et de la Population and Institute for Resource Development (IRD)/Macro Systems. 1989. Enquête Démographique et de Santé en Tunisie 1988. Tunis, p. 68. Turkey Hacettepe Institute of Population Studies and CDC. 1989. 1988 Turkish Population and Health Survey. Ankara, Tables II.6.18 and II.4.1. Ministry of Health, General Directorate of Mother and Child Health and Family Planning, and Macro International. 1994. Turkey Demographic and Health Survey 1993. Calverton, MD. © 2002 EngenderHealth 42 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Yemen Central Statistical Organization, Pan Arab Project for Child Development, and Macro Interna- tional. 1992. Yemen Demographic and Maternal and Child Health Survey 1991/92: Prelim- inary report. Calverton, MD. Central Statistical Organization and Macro International. 1998. Demographic and Maternal and Child Health Survey 1997. Calverton, MD. Sub-Saharan Africa Benin Institut National de la Statistique et de l’Analyse Économique and Macro International. 1997. Bénin Enquête Démographique et de Santé 1996. Calverton, MD. Botswana Manyeneng, W. G., et al. 1985. Botswana Family Health Survey 1984. Gaborone, Botswana: Family Health Division, Ministry of Health, and Westinghouse Public Applied Systems, pp. 147, 150, 151. Family Health Division, Ministry of Health, and Macro Systems. 1989. Botswana Family Health Survey II 1988. Columbia, MD, p. 42. Burkina Faso Institut National de la Statistique et de la Démographie and Macro International. 1994. Burkina Faso Enquête Démographique et de Santé 1993. Calverton, MD. Burundi Ministère de I’Interieur, Département de la Population, and Institute for Resource Develop- ment/Westinghouse. 1988. Enquête Démographique et de Santé au Burundi 1987. Gitega, Burundi, p. 4. Cameroon Direction Nationale du Deuxieme Recensement General de la Population et de l’Habitat and Macro International. 1992. Enquête Démographique et de Santé Cameroun 1991. Calverton, MD. Bureau Central des Recensement et des Études de Population and Macro International. 1999. Cameroun Enquête Démographique et de Santé 1998. Calverton, MD. Cape Verde CDC and Instituto Nacional de Estatistica. 1998. Inquerito Demografico e de Saude Reprodutiva. Atlanta. Central African Republic Division des Statistiques et des Études Economiques and Macro International. 1995. Republique Centrafricaine Enquête Démographique et de Santé 1994–95. Calverton, MD. Chad Bureau Central du Recensement, Direction de la Statistique, and Macro International. 1998. Chad Enquête Démographique et de Santé 1996/1997. Calverton, MD. Comoros Centre National de Documentation et de Recherche Scientifique and Macro International. 1997. Enquête Démographique et de Santé aux Comores 1996. Calverton, MD. Côte d’ Ivoire Institut National de la Statistique and Macro International. 1995. Côte d’Ivoire Enquête Démo- graphique et de Santé 1994. Calverton, MD. Institut National de la Statistique and Macro International. 1999. Côte d’Ivoire Enquête Démo- graphique et de Santé 1998–1999. Calverton, MD. Eritrea National Statistics Office and Macro International. 1997. Eritrea Demographic and Health Sur- vey 1995. Calverton, MD. © 2002 EngenderHealth Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 43 Ethiopia Central Statistical Authority. 1991. The 1990 Family and Fertility Survey: Preliminary report. Addis Ababa, Tables 4.1 and 4.6. Ghana Statistical Service and Macro Systems. 1989. Ghana Demographic and Health Survey 1988. Ac- cra, p. 36. Statistical Service and Macro International. 1994. Ghana Demographic and Health Survey 1993. Calverton, MD. Ghana Statistical Service and Macro International. 1999. Demographic and Health Survey 1998. Accra and Calverton, MD. Kenya Central Bureau of Statistics. 1984. Kenya Contraceptive Prevalence Survey 1984—First report. Nairobi: Ministry of Planning and National Development, p. 86. National Council for Population and Macro Systems. 1989. Kenya Demographic and Health Sur- vey 1989. Columbia, MD, p. 35. Central Bureau of Statistics, National Council for Population and Development, and Macro Inter- national. 1994. Kenya Demographic and Health Survey 1993. Calverton, MD. Central Bureau of Statistics, National Council for Population and Development, and Macro Inter- national. 1998. Kenya Demographic and Health Survey 1998—Preliminary report. Calver- ton, MD. Liberia Bureau of Statistics, Ministry of Planning and Economic Affairs, and Institute for Resource De- velopment/Westinghouse. 1988. Liberia Demographic and Health Survey 1986. Monrovia and Columbia, MD, p. 41. Madagascar Ministère de la Recherche Appliquée au Développement and Macro International. 1994. Mada- gascar Enquête Nationale Démographique et Sanitaire 1992. Calverton, MD. Institut National de la Statistique and Macro International. 1998. Madagascar Enquête Démo- graphique et de Santé 1997. Calverton, MD. Malawi National Statistical Office and Macro International. 1994. Malawi Demographic and Health Sur- vey 1992. Calverton, MD. National Statistical Office and Macro International. 1997. Malawi Knowledge, Attitudes and Practices in Health Survey 1996. Calverton, MD. Mali Centre des Études et de Recherche sur la Population pour le Developpement and Institute for Re- source Development/Westinghouse. 1989. Enquête Démographique et de Santé au Mali 1987. Bamako and Columbia, MD, p. 49. Ministère de la Santé, de la Solidarité et des Personnes Âgées and Macro International. 1996. Mali Enquête Démographique et de Santé 1995/1996. Calverton, MD: Cellule de Planification et de Statistique and Macro International. Mauritius Ministry of Health and CDC. 1987. Mauritius Contraceptive Prevalence Survey 1985—Final re- port. Port Louis: Evaluation Unit, Family Planning/Maternal-Child Health Division, Min- istry of Health, Table 26. Ministry of Health and CDC. 1993. Mauritius Contraceptive Prevalence Survey 1991—Final re- port. Atlanta. Mozambique Instituto Nacional de Estatistica and Macro International. 1997. Moçambique lnquérito De- mográfico e de Saúde 1997. Calverton, MD. Namibia Ministry of Health and Social Services and Macro International. 1993. Namibia Demographic and Health Survey 1992. Calverton, MD. © 2002 EngenderHealth 44 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Niger Direction de la Statistique et des Comptes Nationaux Direction Générale du Plan Ministère des Finances et du Plan and Macro International. 1992. Enquête Démographique et de Saudé Niger 1992—Rapport préliminaire. Calverton, MD. Care International and Macro International. 1999. Enquête Démographique et de Santé Niger 1998. Calverton, MD. Nigeria Ministry of Health, Medical/Preventive Health Division, and Macro Systems. 1989. Ondo State, Nigeria, Demographic and Health Survey 1986. Columbia, MD. Federal Office of Statistics and Demographic and Health Survey and Macro Systems. 1991. Nige- ria Demographic and Health Survey 1990, Preliminary report. Lagos, p. 8 (Table 4). Rwanda Office National de la Population. 1985. Rwanda 1983 Enquête Nationale sur la Fécondité. Kigali, Tables 6.6, 6.7, 7.4, 7.7, 7.10. Office National de la Population and Macro International. 1994. Rwanda Enquête Démo- graphique et de Santé 1992. Calverton, MD. Senegal Division des Statistiques Démographiques and Macro International. 1994. Enquête Démo- graphique et de Santé au Senegal 1992/93. Calverton, MD. Division des Statistiques Démographiques and Macro International. 1997. Enquête Démo- graphique et de Santé au Senegal 1997. Calverton, MD. South Africa Department of Health and Macro International. 1998. South Africa Demographic and Health Sur- vey 1998—Preliminary report. Pretoria. Sudan Department of Statistics, Ministry of Economic and National Planning, and Macro Systems. 1990. Sudan Demographic and Health Survey 1989–1990. Khartoum, p. 42. Swaziland Ministry of Health and CDC. 1990. Swaziland 1988 Family Health Survey—Final report. Atlanta. Tanzania Planning Commission, Bureau of Statistics, and Macro International. 1993. Tanzania Demo- graphic and Health Survey 1991/1992. Calverton, MD. Planning Commission, Bureau of Statistics, and Macro International. 1995. Tanzania Knowledge, Attitudes and Practices Survey 1994. Calverton, MD. Planning Commission, Bureau of Statistics, and Macro International. 1997. Tanzania Demo- graphic and Health Survey 1996. Calverton, MD. Togo Unite de Recherche Démographique, Université de Benin, and Macro Systems. 1989. Enquête Démographique et de Santé au Togo 1988. Lome, p. 45. Direction de la Statistique and Macro International. 1999. Togo Enquête Démographique et de Santé 1998. Lome and Columbia, MD. Uganda Ministry of Health and Macro Systems. 1989. Uganda Demographic and Health Survey 1988–1989. Entebbe, p. 33. Statistics Department and Macro International. 1996. Uganda Demographic and Health Survey 1995. Calverton, MD. Zambia University of Zambia, Central Statistical Office, and Macro International. 1993. Zambia Demo- graphic and Health Survey 1992. Calverton, MD. Central Statistical Office, Ministry of Health, and Macro International. 1997. Zambia Demo- graphic and Health Survey 1996. Calverton, MD. © 2002 EngenderHealth Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 45 Zimbabwe Central Statistical Office, Ministry of Finance, Economic Planning, and Macro Systems. 1989. Zimbabwe Demographic and Health Survey 1988. Harare, p. 51. Central Statistical Office and Macro International. 1995. Zimbabwe Demographic and Health Survey 1994. Calverton, MD. North America United States Chandra, A. 1998. Surgical sterilization in the United States: Prevalence and characteristics, 1965–1995. Vital and Health Statistics, series 23, no. 20. Hyattsville, MD: National Center for Health Statistics. Eastern Europe and Central Asian Republics Azerbaijan Serbanescu, F., et al. 2002. Azerbaijan Reproductive Health Survey, 2001—Preliminary report. Baku: Adventist Development and Relief Assistance and Mercy Corps International; and At- lanta: CDC. Czech Republic Czech Statistical Office and CDC. 1995. Czech Republic Reproductive Health Survey 1993. Fi- nal report. Atlanta. Georgia Serbanescu, F., et al. 2000. Reproductive Health Survey, Georgia, 1999–2000. Final Report. Tbil- isi: Georgian National Center for Disease Control; and Atlanta: CDC. Kazakhstan Academy of Preventive Medicine of Kazakhstan and Macro International. 1999. Kazakhstan De- mographic and Health Survey, 1999: Preliminary report. Almaty. Kyrgyz Republic Ministry of Health of the Kyrgyz Republic and Macro International. 1998. Kyrgyz Republic De- mographic and Health Survey 1997. Calverton, MD. Moldova Moldovan Ministry of Health and CDC. 1998. Reproductive Health Survey Moldova, 1997— Final report. Atlanta. Romania Institute for Mother and Child Health Care and CDC. 1995. Romania Reproductive Health Sur- vey 1993. Final report. Atlanta. Romanian Association of Public Health and Health Management and CDC. 2000. Romania Re- productive Health Survey 1999. Preliminary report. Atlanta. Russia All-Russian Centre for Public Opinion and Market Research and CDC. 1998. 1996 Russian Women’s Reproductive Health Survey: A study of three sites. Moscow and Atlanta. Ukraine CDC and Kiev International Institute of Sociology. 2000. Ukraine Reproductive Health Survey. Atlanta. Uzbekistan Ministry of Health of the Republic of Uzbekistan and Macro International. 1997. Uzbekistan De- mographic and Health Survey 1996. Calverton, MD. © 2002 EngenderHealth (cont’d.) 46 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Other Countries Data were taken from UN Population Division. 1999. Levels and trends of contraceptive use as assessed in 1998, New York, for the following countries and years: Algeria, 1986–1987; Bahrain, 1989 and 1995; Barbados, 1988; Belarus, 1995; Belgium, 1991; Bhutan, 1994; Botswana, 1984; Canada, 1984 and 1995; Congo, Democratic Republic of (Kinshasa), 1991; Cuba, 1987; Den- mark, 1988; Dominica, 1987; Ethiopia, 1990; Gambia, 1990; Germany, 1985 and 1992; Guinea, 1992–1993; Honduras, 1987 and 1991–1992; Iran, 1992; Iraq, 1989; Japan, 1986, 1988, 1990, and 1994; Kenya, 1984; Korea, Republic of, 1985, 1988, and 1991; Kuwait, 1987; Lao People’s De- mocratic Republic, 1993; Lesotho, 1991–1992; Malaysia, 1988; Mexico, 1995; Mongolia, 1994; Myanmar, 1992; New Zealand, 1995; Oman, 1988 and 1995; Pakistan, 1994–1995; Papua New Guinea, 1996; Qatar, 1987; Rwanda, 1983; South Africa, 1988; Spain, 1985; Sri Lanka, 1993; Su- dan (Northern), 1992–1993; Thailand, 1993; United Arab Emirates, 1995; United Kingdom, 1986 and 1993; and United States, 1988 and 1990. Data were taken from U.S. Bureau of the Census. 1999. World Population Profile: 1998. Report WP/98. Washington, DC: Government Printing Office, for the following countries and years: Al- geria, 1992; Antigua and Barbuda, 1988; Australia, 1986; Bahamas, 1988; Bangladesh, 1985, 1989, and 1991; Belize, 1985; Bolivia, 1989 and 1993–1994; Brazil, 1986; China, 1988; Domini- can Republic, 1986 and 1991; Ecuador, 1987; Egypt, 1984; Finland, 1989 and 1994; France, 1988 and 1994; Ghana, 1995; Hong Kong, 1984 and 1987; Hungary, 1993; India, 1988 and 1990; In- donesia, 1985; Latvia, 1995; Lebanon, 1996; Libya, 1995; Mexico, 1987; Namibia, 1989; Nepal, 1986 and 1991; Netherlands, 1985, 1988, and 1993; Norway, 1988–1989; Paraguay, 1990; Peru, 1986; Philippines, 1988, 1995, and 1996; Reunion, 1990; Saint Lucia, 1988; Saint Vincent and the Grenadines, 1988; Slovakia, 1991; Slovenia, 1989; Switzerland, 1995; Syria, 1993; Tanzania, 1988; Thailand, 1985; Tunisia, 1994; United Kingdom, 1989; and Vietnam, 1988 and 1994. © 2002 EngenderHealth © 2002 EngenderHealth Supplement 2.1. Number (in millions) of women of reproductive age currently in union who are using sterilization, by type of sterilization, according to region Male Female Region Total sterilization sterilization Worldwide 222.359 42.580 179.779 Asia 179.661 32.702 146.959 Oceania 1.248 0.372 0.876 Latin America and the Caribbean 15.999 0.793 15.206 North America and Western Europe 21.414 8.497 12.917 Eastern Europe and Central Asia 0.372 0.000 0.372 Middle East 1.482 0.104 1.378 Africa 2.183 0.112 2.071 Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 47 Supplement 2.2. Percentage and number of women of reproductive age currently in union who are using sterilization, by type of sterilization, according to region and country No. of No. of No. of couples couples women Total no. using male using female% using sterilization in union* of users† sterilization sterilization Country/year Source Total Male Female (in millions) (in millions) (in millions) (in millions) Notes Asia 179.865 32.702 146.959 Bangladesh, 1996–1997 DHS 8.7 1.1 7.6 22.3 1.940 0.245 1.695 1 Bhutan, 1994 UN/ESA 11.1 8.0 3.1 0.3 0.033 0.024 0.009 2 China, 1992 CDC 46.1 10.2 35.9 238.9 110.133 24.368 85.765 Hong Kong, 1987 WP/98 Survey 23.8 0.9 22.9 1.0 0.238 0.009 0.229 India, 1992–1993 DHS 30.7 3.4 27.3 177.5 54.493 6.035 48.458 3 Indonesia, 1997 DHS 3.4 0.4 3.0 34.9 1.187 0.140 1.047 Japan, 1994 UN/ESA 4.1 0.7 3.4 18.4 0.754 0.129 0.626 Korea, Republic of, 1991 UN/ESA 47.3 12.0 35.3 8.0 3.784 0.960 2.824 4 Lao People’s Democratic UN/ESA 5.1 NA 5.1 0.7 0.036 NA 0.036 Republic, 1993 Malaysia, 1988 UN/ESA 6.8 NA NA 3.0 0.204 NA NA 5 Mongolia, 1994 UN/ESA 0.9 0.3 0.6 0.4 0.004 0.001 0.002 Myanmar, 1992 UN/ESA 5.5 1.8 3.7 6.8 0.374 0.122 0.252 Nepal, 1996 DHS 17.5 5.4 12.1 4.0 0.700 0.216 0.484 Pakistan, 1994–1995 UN/ESA 5.0 Z 5.0 21.3 1.065 NA 1.065 Philippines, 1998 DHS 10.4 0.1 10.3 10.7 1.113 0.011 1.102 Sri Lanka, 1993 UN/ESA 27.2 3.7 23.5 2.9 0.789 0.107 0.682 6 Thailand, 1993 UN/ESA 22.6 2.8 19.8 9.9 2.237 0.277 1.960 4 Vietnam, 1997 DHS 6.8 0.5 6.3 11.5 0.782 0.058 0.725 Oceania 1.248 0.372 0.876 Australia, 1986 WP/98 Survey 38.1 10.4 27.7 2.7 1.029 0.281 0.748 7 New Zealand, 1995 UN/ESA 33.0 18.0 15.0 0.5 0.165 0.090 0.075 7, 8 Papua New Guinea, 1996 UN/ESA 7.8 0.2 7.6 0.7 0.055 0.001 0.053 (cont’d.) (cont’d.) Latin America and the Caribbean 16.158 0.793 15.206 Antigua and Barbuda, WP/98 CPS 11.0 NA 11.0 NA NA NA NA 4 1988 Bahamas, 1988 WP/98 CPS 17.2 NA 17.2 NA NA NA NA 4 Barbados, 1988 UN/ESA 10.7 0.3 10.4 NA NA NA NA Belize, 1991 CDC 18.7 NA 18.7 NA NA NA NA 4 Bolivia, 1998 DHS 6.5 Z 6.5 1.1 0.072 NA 0.072 Brazil, 1996 DHS 42.7 2.6 40.1 26.8 11.444 0.697 10.747 Colombia, 1995 DHS 26.4 0.7 25.7 5.2 1.373 0.036 1.336 Costa Rica, 1993 CDC 21.0 1.3 19.7 0.5 0.105 0.007 0.099 Cuba, 1987 UN/ESA 22.0 NA 22.0 1.9 0.418 NA 0.418 Dominica, 1987 UN/ESA 12.6 NA 12.6 NA NA NA NA 4 Dominican Republic, DHS 41.0 0.1 40.9 1.1 0.451 0.001 0.450 1996 Ecuador, 1999 CDC 22.5 NA 22.5 1.9 0.428 NA 0.428 El Salvador, 1998 CDC 32.4 NA 32.4 0.9 0.292 NA 0.292 4, 9 Guatemala, 1995 DHS 15.8 1.5 14.3 1.5 0.237 0.023 0.215 Haiti, 1994–1995 DHS 3.1 NA 3.1 1.1 0.034 NA 0.034 Honduras, 1996 CDC 18.1 NA 18.1 0.8 0.145 NA 0.145 4 Jamaica, 1997 CDC 12.3 NA 12.3 0.5 0.062 NA 0.062 Mexico, 1995 UN/ESA 27.3 NA NA 14.6 0.160 NA NA 8 Nicaragua, 1998 DHS 26.6 0.5 26.1 0.6 0.160 0.003 0.157 Panama, 1984 CDC 33.5 0.4 33.1 0.4 0.134 0.002 0.132 4 Paraguay, 1998 CDC 8.0 Z 8.0 0.7 0.056 NA 0.056 4 Peru, 1996 DHS 9.7 0.2 9.5 3.4 0.330 0.007 0.323 Puerto Rico, 1995–1996 CDC 48.7 3.5 45.2 0.5 0.244 0.018 0.226 Saint Lucia, 1988 WP/98 CPS 8.6 Z 8.6 NA NA NA NA 4 Saint Vincent and the WP/98 CPS 13.1 Z 13.1 NA NA NA NA 4 Grenadines, 1988 Trinidad and Tobago, DHS 8.4 0.2 8.2 0.2 0.017 0.000 0.016 1987 North America 16.551 6.303 10.248 Canada, 1995 UN/ESA 46.0 16.2 29.8 4.6 2.116 0.745 1.371 8 United States, 1995 VHS 38.7 14.9 23.8 37.3 14.435 5.558 8.877 4 Western Europe 4.863 2.194 2.669 Belgium, 1991 UN/ESA 19.1 7.6 11.5 1.7 0.325 0.129 0.196 10, 11, 12 Denmark, 1988 UN/ESA 10.0 5.0 5.0 0.7 0.070 0.035 0.035 4, 13 Supplement 2.2. Percentage and number of women of reproductive age currently in union who are using sterilization, by type of sterilization, according to region and country (cont’d.) No. of No. of No. of couples couples women Total no. using male using female% using sterilization in union* of users† sterilization sterilization Country/year Source Total Male Female (in millions) (in millions) (in millions) (in millions) Notes 48 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS © 2002 EngenderHealth Supplement 2.2. Percentage and number of women of reproductive age currently in union who are using sterilization, by type of sterilization, according to region and country (cont’d.) No. of No. of No. of couples couples women Total no. using male using female% using sterilization in union* of users† sterilization sterilization Country/year Source Total Male Female (in millions) (in millions) (in millions) (in millions) Notes Western Europe (cont’d.) Finland, 1994 WP/98 Survey 9.3 1.0 8.3 0.7 0.065 0.007 0.058 14 France, 1994 WP/98 Survey 4.9 0.3 4.6 8.8 0.431 0.026 0.405 Germany, 1992 UN/ESA 0.9 NA 0.9 12.0 0.108 NA 0.108 15 Netherlands, 1993 WP/98 Survey 13.0 9.0 4.0 2.2 0.286 0.198 0.088 16 Norway, 1988–1989 WP/98 Survey 14.7 4.3 10.4 0.5 0.074 0.022 0.052 17 Spain, 1985 UN/ESA 4.6 0.3 4.3 6.7 0.308 0.020 0.288 18 Switzerland, 1995 WP/98 Survey 22.0 8.3 13.7 1.0 0.220 0.083 0.137 7, 19 United Kingdom, 1993 UN/ESA 32.0 18.0 14.0 9.3 2.976 1.674 1.302 20, 21 Eastern Europe and Central Asia 0.487 0.000 0.372 Azerbaijan, 2001 CDC 1.2 Z 1.2 1.0 0.012 NA 0.012 4 Belarus, 1995 UN/ESA 0.8 Z 0.8 1.8 0.014 NA NA 22 Czech Republic, 1993 CDC 2.7 NA 2.7 1.9 0.051 NA 0.051 4 Georgia, 1999 CDC 1.6 Z 1.6 0.7 0.012 0.000 0.012 Hungary, 1993 WP/98 Survey 5.1 NA NA 1.8 0.092 NA NA 23 Kazakhstan, 1995 DHS 0.7 NA 0.7 3.0 0.021 NA 0.021 Kyrgyz Republic, 1997 DHS 1.8 NA 1.8 NA NA NA NA Latvia, 1995 WP/98 Survey 2.1 NA NA 0.4 0.008 NA NA 18 Moldova, 1997 CDC 3.4 NA 3.4 0.8 0.027 NA 0.027 2 Romania, 1999 CDC 2.5 Z 2.5 3.2 0.080 0.000 0.080 Russia, 1996 CDC 2.0 NA 2.0 NA NA NA NA 4, 24 Slovakia, 1991 WP/98 UN 4.0 Z 4.0 1.0 0.040 NA 0.040 4, 13 Slovenia, 1989 WP/98 Survey 0.2 NA NA NA NA NA NA 4 Ukraine, 1999 CDC 1.4 Z 1.4 7.3 0.102 0.000 0.102 Uzbekistan, 1996 DHS 0.7 NA 0.7 3.8 0.027 NA 0.027 Middle East 1.482 0.104 1.378 Bahrain, 1995 UN/ESA 7.1 1.1 6.0 0.1 0.007 0.001 0.006 8, 25 Iran, 1992 UN/ESA 8.5 0.9 7.6 11.2 0.952 0.101 0.851 4 Iraq, 1989 UN/ESA 1.4 NA 1.4 2.8 0.039 NA 0.039 25 Jordan, 1997 DHS 4.2 NA 4.2 0.7 0.029 NA 0.029 Kuwait, 1987 UN/ESA 2.0 NA 2.0 0.3 0.006 NA 0.006 25, 26 Lebanon, 1996 WP/98 PAPCHILD 4.2 NA 4.2 0.5 0.021 NA 0.021 Oman, 1995 UN/ESA 4.5 Z 4.5 0.3 0.014 NA 0.014 8, 25 Qatar, 1987 UN/ESA 4.5 NA 4.5 0.1 0.005 NA 0.005 26 Syria, 1993 WP/98 PAPCHILD 2.2 Z 2.2 2.1 0.046 NA 0.046 Turkey, 1993 DHS 2.9 Z 2.9 11.1 0.322 NA 0.322 (cont’d.) Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 49 © 2002 EngenderHealth Middle East (cont’d.) United Arab Emirates, UN/ESA 4.3 0.1 4.2 0.2 0.009 0.000 0.008 8, 25 1995 Yemen, 1997 DHS 1.5 0.1 1.4 2.2 0.033 0.002 0.031 Sub-Saharan Africa 1.675 0.112 1.563 Benin, 1996 DHS 0.4 NA 0.4 1.0 0.004 NA 0.004 Botswana, 1988 DHS 4.6 0.3 4.3 0.1 0.005 0.000 0.004 Burkina Faso, 1992–1993 DHS 0.2 Z 0.2 1.8 0.004 NA 0.004 Burundi, 1987 DHS 0.1 NA 0.1 0.9 0.001 NA 0.001 Cameroon, 1998 DHS 1.5 NA 1.5 1.9 0.029 NA 0.029 Cape Verde, 1998 CDC 12.8 Z 12.8 0.1 0.015 0.000 0.015 Central African Republic, DHS 0.4 NA 0.4 0.5 0.002 NA 0.002 1994–1995 Chad, 1996–1997 DHS 0.2 Z 0.2 NA NA NA NA Comoros, 1996 DHS 2.8 NA 2.8 0.1 0.003 NA 0.003 Congo, Democratic UN/ESA 0.3 0.1 0.2 6.7 0.020 0.007 0.013 Republic of (Kinshasa), 1991 Côte d’Ivoire, 1998–1999 DHS 0.1 NA 0.1 2.3 0.002 NA 0.002 Eritrea, 1995–1996 DHS 0.3 NA 0.3 0.6 0.002 NA 0.002 Ethiopia, 1990 UN/ESA 0.2 Z 0.2 9.2 0.018 NA 0.018 27, 28 Gambia, 1990 UN/ESA 0.4 Z 0.4 0.2 0.001 NA 0.001 Ghana, 1998 DHS 1.3 Z 1.3 2.7 0.035 NA 0.035 Guinea, 1992–1993 UN/ESA 0.1 Z 0.1 1.2 0.001 NA 0.001 Kenya, 1998 DHS 6.2 NA 6.2 3.9 0.242 NA 0.242 Lesotho, 1991–1992 UN/ESA 1.4 Z 1.4 0.2 0.003 NA 0.003 Liberia, 1986 DHS 1.1 NA 1.1 0.3 0.003 NA 0.003 Madagascar, 1997 DHS 1.0 Z 1.0 2.1 0.021 NA 0.021 Malawi, 1996 DHS 2.5 NA 2.5 1.4 0.035 NA 0.035 Mali, 1995–1996 DHS 0.3 NA 0.3 2.2 0.007 NA 0.007 Mauritius, 1991 CDC 7.2 Z 7.2 0.2 0.014 NA 0.014 4 Mozambique, 1997 DHS 0.7 NA 0.7 3.0 0.021 NA 0.021 Namibia, 1992 DHS 7.6 0.2 7.4 0.2 0.015 0.000 0.015 Niger, 1998 DHS 0.1 NA 0.1 1.5 0.002 NA 0.002 Nigeria, 1990 DHS 0.3 NA 0.3 19.1 0.057 NA 0.057 Réunion, 1990 WP/98 Survey 5.1 Z 5.1 0.1 0.005 NA 0.005 Rwanda, 1992 DHS 0.7 NA 0.7 0.7 0.005 NA 0.005 Senegal, 1997 DHS 0.5 NA 0.5 1.4 0.007 NA 0.007 (cont’d.) 50 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS Supplement 2.2. Percentage and number of women of reproductive age currently in union who are using sterilization, by type of sterilization, according to region and country (cont’d.) No. of No. of No. of couples couples women Total no. using male using female% using sterilization in union* of users† sterilization sterilization Country/year Source Total Male Female (in millions) (in millions) (in millions) (in millions) Notes © 2002 EngenderHealth Sub-Saharan Africa (cont’d.) South Africa, 1998 DHS 17.9 2.1 15.8 4.8 0.859 0.101 0.758 Sudan (Northern), UN/ESA 0.9 Z 0.9 4.2 0.038 NA 0.038 1992–1993 Swaziland, 1988 CDC 5.0 0.3 4.7 0.1 0.005 0.000 0.005 29 Tanzania, 1996 DHS 1.9 NA 1.9 4.6 0.087 NA 0.087 Togo, 1998 DHS 0.4 NA 0.4 0.7 0.003 NA 0.003 Uganda, 1995 DHS 1.4 NA 1.4 2.9 0.041 NA 0.041 Zambia, 1996 DHS 2.0 Z 2.0 1.2 0.024 NA 0.024 Zimbabwe, 1994 DHS 2.5 0.2 2.3 1.6 0.040 0.003 0.037 North Africa 0.508 0.000 0.508 Algeria, 1992 WP/98 PAPCHILD 1.1 Z 1.1 4.0 0.044 NA 0.044 Egypt, 1995–1996 DHS 1.1 NA 1.1 10.0 0.110 NA 0.110 Libya, 1995 WP/98 PAPCHILD 3.8 NA 3.8 0.7 0.027 NA 0.027 Morocco, 1995 DHS 4.3 NA 4.3 3.8 0.163 NA 0.163 Tunisia, 1994 WP/98 PAPCHILD 12.6 NA 12.6 1.3 0.164 NA 0.164 * Based on 1995 UN estimates from censuses and surveys. † Total may exceed sum of male and female sterilizations because for some countries totals are the only data available. Source notes: CDC � data from a maternal health, contraceptive prevalence or reproductive health survey conducted by the Division of Reproductive Health, U.S. Centers for Disease Control and Prevention (CDC). CPS � data from Contraceptive Prevalence Survey program data (either Westinghouse Health Systems or the CDC). DHS � Demographic and Health Survey data. PAPCHILD � data from the Pan Arab Project for Child Development of the League of Arab States. Survey � data taken from a nationwide survey conducted by a national government or independent organization that is not a contraceptive prevalence survey or survey conducted as part of the DHS or World Fertility Survey. UN/ESA � data from the United Nations Department of Economic and Social Affairs, Population Division, as published in UN Population Division, 1999. VHS � U.S. Vital and Health Statistics. WP/98 � data taken from U.S. Bureau of the Census, World Population Profile, 1998. NA � data not available. Z � negligible (�0.1%). Supplement 2.2. Percentage and number of women of reproductive age currently in union who are using sterilization, by type of sterilization, according to region and country (cont’d.) No. of No. of No. of couples couples women Total no. using male using female% using sterilization in union* of users† sterilization sterilization Country/year Source Total Male Female (in millions) (in millions) (in millions) (in millions) Notes Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 51 18. Data refer to women aged 18–49. 19. From unpublished tables, Swiss Federal Statistical Office, Family and Fertility Survey 1994–1995. 20. Data refer to women aged 16–49. 21. Data refer to Great Britain, and do not include Northern Ireland. 22. Data refer to women aged 18–34. 23. Data refer to women aged 18–41. 24. Survey was limited to three sites (Ivanovo, Yekaterinburg, and Perm); the percentages noted here represent averages. 25. Data refer to nationals only. 26. Data refer to ages �50. 27. Data refer to ever-married women. 28. Excludes Eritrea, Tigray, Asseb, Ogaden, parts of Gondar and Wello, and nomadic populations. 29. Data refer to ever-married women and unmarried women who have had a child. Explanatory notes: 1. Data refer to women aged 10–49. 2. Data refer to all women aged 15–49, regardless of marital status. 3. Data refer to women aged 13–49. 4. Data refer to women aged 15–44. 5. Data refer to peninsular Malaysia only. 6. Coverage is not national. 7. Data refer to women aged 20–49. 8. Preliminary or provisional data. 9. Male sterilization rates represent �0.7%. 10. Data refer to women aged 20–54. 11. Data refer to the Flemish population only. 12. Data include individuals sterilized for noncontraceptive purposes. 13. Data refer to all sexually active women. 14. Data refer to women aged 18–44. 15. Data refer to women aged 20–39. 16. Data refer to women aged 18–42. 17. Data are for women born in 1945, 1950, 1965, and 1968 only. These women were 20, 23, 28, and 43 at the time of the survey. © 2002 EngenderHealth Supplement 2.3. Approximate annual incidence of female sterilization per 100 women of reproductive age who were ever in union, by number of years prior to survey No. of years prior to survey Country/year/source 5 4 3 2 1 5-year average Bangladesh, 1987 (DHS) 1.9 2.5 2.4 2.3 1.8 2.2 Bangladesh, 1993–1994 (DHS) 0.5 0.5 0.5 0.3 0.2 0.4 Bangladesh, 1996–1997 (DHS) 0.4 0.3 0.2 0.2 0.1 0.2 Belize, 1991 (CDC)* 1.6 1.3 1.5 2.4 1.6 1.7 Bolivia, 1989 (DHS) 0.4 0.4 0.4 0.2 0.5 0.4 Bolivia, 1993–1994 (DHS) 0.4 0.2 0.4 0.4 0.5 0.4 Bolivia, 1998 (DHS) 0.5 0.4 0.6 0.5 0.7 0.5 Brazil, 1986 (DHS)* 2.8 3.3 2.6 2.7 3.4 3.0 Brazil, 1991 (DHS)† 2.4 3.5 3.5 3.4 3.7 3.3 Brazil, 1996 (DHS) 2.1 2.7 2.5 2.6 2.5 2.5 Cape Verde, 1998 (CDC) 1.1 1.5 1.5 1.2 1.7 1.4 Colombia, 1986 (DHS) 1.4 1.7 1.9 1.7 2.0 1.7 Colombia, 1990 (DHS) 1.2 1.6 2.3 1.5 2.1 1.7 Colombia, 1995 (DHS) 1.5 1.6 2.1 1.8 1.9 1.8 Costa Rica, 1993 (CDC) 1.2 1.0 2.2 1.5 2.0 1.6 Dominican Republic, 1986 (DHS) 2.2 2.1 3.1 2.5 3.5 2.7 Dominican Republic, 1991 (DHS) 3.1 2.4 2.9 2.5 3.5 2.9 Dominican Republic, 1996 (DHS) 2.4 2.4 2.8 2.9 2.6 2.6 Ecuador, 1987 (DHS) 1.5 1.0 1.3 1.6 1.5 1.4 Ecuador, 1989 (CDC) 1.3 1.4 1.3 1.6 1.5 1.4 Ecuador, 1994 (CDC) 1.3 1.5 1.5 1.4 1.8 1.5 Ecuador, 1999 (CDC) 1.4 1.5 1.7 1.7 1.8 1.6 Egypt, 1989 (DHS) 0.1 0.1 0.1 0.2 0.1 0.1 Egypt, 1992 (DHS) 0.1 0.1 0.1 0.1 0.1 0.1 Egypt, 1995–1996 (DHS) 0.1 0.1 0.0 0.1 0.1 0.1 El Salvador, 1985 (DHS) 3.2 2.4 2.9 3.1 3.2 3.0 El Salvador, 1988 (CDC)* 2.1 2.8 2.3 2.7 2.5 2.5 El Salvador, 1993 (CDC) 1.5 1.8 2.0 2.5 2.2 2.0 El Salvador, 1998 (CDC) 1.7 1.8 1.7 2.0 2.3 1.9 Ghana, 1988 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Ghana, 1993–1994 (DHS) 0.1 0.1 0.2 0.1 0.1 0.1 Guatemala, 1987 (DHS)* 0.9 1.0 1.1 0.9 0.9 1.0 Guatemala, 1995 (DHS) 1.1 0.8 1.0 1.0 1.3 1.0 Honduras, 1996 (CDC) 1.2 1.2 1.9 1.6 1.8 1.5 India, 1992–1993 (DHS) 2.0 1.7 1.8 2.0 1.7 1.8 Indonesia, 1987 (DHS) 0.3 0.3 0.3 0.4 0.3 0.3 Indonesia, 1991 (DHS) 0.2 0.2 0.2 0.2 0.2 0.2 Indonesia, 1994 (DHS) 0.2 0.2 0.2 0.2 0.3 0.2 Indonesia, 1997 (DHS) 0.1 0.2 0.1 0.2 0.2 0.2 Jamaica, 1997 (CDC) 1.1 0.5 0.8 0.9 0.7 0.8 Jordan, 1990 (DHS)‡ 0.4 0.5 0.6 0.6 0.5 0.5 Kenya, 1989 0.0 0.0 0.0 0.0 0.0 0.0 Kenya, 1993 (DHS) 0.6 0.7 0.5 0.8 0.8 0.7 Kenya, 1998 (DHS) 0.5 0.3 0.5 0.4 0.5 0.4 (cont’d.) 52 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS © 2002 EngenderHealth Mauritius, 1985 (CDC)§ 0.5 0.4 0.4 0.5 0.5 0.5 Mauritius, 1991 (CDC)* 0.8 0.6 0.5 1.1 0.7 0.7 Mexico, 1987 (DHS) 1.3 1.5 2.0 2.3 2.3 1.9 Morocco, 1987 (DHS) 0.2 0.2 0.2 0.3 0.2 0.2 Morocco, 1992 (DHS) 0.1 0.3 0.2 0.2 0.4 0.2 Namibia, 1992 (DHS) 0.5 0.6 0.7 0.6 0.9 0.7 Nepal, 1996 0.7 0.7 1.1 1.2 1.4 1.0 Nicaragua, 1992–1993 (CDC) 1.6 1.7 1.2 1.4 2.3 1.6 Nicaragua, 1998 (DHS) 1.7 2.1 2.6 2.9 3.1 2.5 Panama, 1984 (CDC) 2.2 2.9 3.0 2.9 2.7 2.7 Paraguay, 1987 (CDC)* 0.1 0.5 0.5 0.7 0.4 0.4 Paraguay, 1990 (DHS) 0.5 0.7 0.7 0.9 1.0 0.8 Paraguay, 1995–1996 (CDC) 0.4 0.6 0.5 0.6 0.5 0.5 Paraguay, 1998 (CDC)* 0.5 1.0 0.8 1.0 1.0 0.9 Peru, 1986 (DHS) 0.6 0.5 0.4 0.6 0.4 0.5 Peru, 1991–1992 (DHS) 0.5 0.5 0.6 0.7 0.6 0.6 Peru, 1996 (DHS) 0.5 0.7 0.7 0.9 1.1 0.8 Philippines, 1993 (DHS) 0.7 0.8 0.7 0.7 0.7 0.7 Philippines, 1998 (DHS) 0.4 0.4 0.5 0.5 0.7 0.5 Puerto Rico, 1995–1996 (CDC) 2.4 2.7 2.5 2.2 2.2 2.4 Romania, 1999 (CDC)* 0.1 0.1 0.1 0.2 0.1 0.1 Sri Lanka, 1987 (DHS) 1.9 2.5 2.4 2.3 1.8 2.2 Swaziland, 1988 (CDC) 0.3 0.4 0.2 0.6 0.3 0.4 Tanzania, 1991–1992 (DHS) 0.2 0.2 0.2 0.4 0.3 0.3 Tanzania, 1996 (DHS) 0.2 0.2 0.2 0.2 0.3 0.2 Thailand, 1987 (DHS) 1.7 1.9 1.5 2.3 2.0 1.9 Trinidad and Tobago, 1987 (DHS) 0.4 0.6 0.8 0.9 1.1 0.8 Tunisia, 1988 (DHS) 1.0 1.3 0.9 0.8 1.3 1.1 Turkey, 1993 (DHS) 0.2 0.2 0.3 0.2 0.4 0.3 Ukraine, 1999 (CDC)* 0.1 0.1 0.2 0.2 0.1 0.1 United States, 1988 (NSFG)* 9.2 9.2 7.4 7.5 8.5 8.4 United States, 1995 (NSFG)* 6.3 6.1 6.3 6.9 7.1 6.5 Zambia, 1992 (DHS) 0.2 0.1 0.3 0.2 0.3 0.2 Zambia, 1996–1997 (DHS) 0.1 0.2 0.2 0.2 0.1 0.2 Zimbabwe, 1988–1989 (DHS) 0.2 0.2 0.3 0.3 0.2 0.2 Zimbabwe, 1994 (DHS) 0.2 0.2 0.2 0.4 0.3 0.3 * Data refer to ages 15–44. † Data limited to Northeastern Brazil. ‡ Excludes the West Bank. § Data are not weighted. Note: Data included here were generated at the request of EngenderHealth by Measure-DHS+ and by the Division of Reproductive Health, CDC. Supplement 2.3. Approximate annual incidence of female sterilization per 100 women of reproductive age who were ever in union, by number of years prior to survey (cont’d.) No. of years prior to survey Country/year/source 5 4 3 2 1 5-year average Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 53 © 2002 EngenderHealth Supplement 2.4. Approximate annual incidence of male sterilization among partners of women of reproductive age who were ever in union, per 100 couples ever in union, by number of years prior to survey No. of years prior to survey Country/year/source 5 4 3 2 1 5-year average Bangladesh, 1987 (DHS) 0.5 0.6 0.5 0.4 0.4 0.5 Bangladesh, 1993–1994 (DHS) 0.1 0.0 0.1 0.0 0.0 0.0 Bangladesh, 1996–1997 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Bolivia, 1989 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Bolivia, 1993–1994 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Bolivia, 1998 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Brazil, 1986 (DHS)* 0.1 0.1 0.0 0.1 0.0 0.1 Brazil, 1991 (DHS)† 0.0 0.0 0.0 0.0 0.0 0.0 Brazil, 1996 (DHS) 0.1 0.4 0.3 0.3 0.2 0.3 Colombia, 1986 (DHS) 0.1 0.0 0.0 0.0 0.0 0.0 Colombia, 1990 (DHS) 0.1 0.0 0.1 0.1 0.1 0.1 Colombia, 1995 (DHS) 0.0 0.1 0.1 0.1 0.1 0.1 Dominican Republic, 1986 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Dominican Republic, 1991 (DHS) 0.0 0.0 0.0 0.1 0.0 0.0 Dominican Republic, 1996 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Ecuador, 1987 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Egypt, 1988–1989 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Egypt, 1992 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Egypt, 1995–1996 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 El Salvador, 1985 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Ghana, 1988 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Ghana, 1993–1994 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Guatemala, 1987 (DHS)* 0.1 0.1 0.1 0.1 0.1 0.1 Guatemala, 1995 (DHS) 0.1 0.1 0.1 0.1 0.2 0.1 India, 1992–1993 (DHS) 0.1 0.1 0.1 0.1 0.1 0.1 Indonesia, 1987 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Indonesia, 1991 (DHS) 0.0 0.0 0.0 0.1 0.1 0.0 Indonesia, 1994 (DHS) 0.1 0.1 0.1 0.1 0.0 0.1 Indonesia, 1997 (DHS) 0.0 0.0 0.0 0.1 0.0 0.0 Jordan, 1990 (DHS)‡ 0.0 0.0 0.0 0.0 0.0 0.0 Kenya, 1989 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Kenya, 1993 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Kenya, 1998 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Mexico, 1987 (DHS) 0.0 0.1 0.0 0.1 0.1 0.1 Morocco, 1987 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Morocco, 1992 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Namibia, 1992 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Nepal, 1996 (DHS) 0.3 0.4 0.4 0.4 0.5 0.4 Nicaragua, 1998 (DHS) 0.0 0.0 0.0 0.1 0.0 0.0 Paraguay, 1990 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Peru, 1986 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Peru, 1991–1992 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Peru, 1996 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Philippines, 1993 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Philippines, 1998 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 (cont’d.) 54 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS © 2002 EngenderHealth Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence % using sterilization Sterilization as a % using any % of overall Country/year Source method Total Male Female prevalence Notes Asia Bangladesh 1985 WP/98 CPS 25.3 9.4 1.5 7.9 37.2 1 1989 WP/98 Survey 31.4 10.0 1.2 8.8 31.8 1 1991 WP/98 Survey 39.9 10.3 1.2 9.1 25.8 1 1993–1994 DHS 44.9 9.3 1.1 8.2 20.7 1996–1997 DHS 49.2 8.7 1.1 7.6 17.7 2 Bhutan 1994 UN/ESA 18.8 11.1 8.0 3.1 59.0 3 Cambodia 2000 DHS 23.8 1.5 Z 1.5 6.3 China 1988 WP/98 Survey 71.1 35.0 7.8 27.2 49.2 1992 CDC 84.6 46.1 10.2 35.9 54.5 Hong Kong 1984 WP/98 PC 72.4 21.0 NA NA 29.0 4 1987 WP/98 Survey 80.8 23.8 0.9 22.9 29.5 India 1988 WP/98 Survey 42.9 30.8 NA 30.8 71.8 4 1990 WP/98 Survey 44.9 31.3 NA NA 69.7 4 1992–1993 DHS 40.6 30.7 3.4 27.3 75.6 5 Sri Lanka, 1987 (DHS) 0.5 0.6 0.5 0.4 0.4 0.5 Tanzania, 1991–1992 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Tanzania, 1996 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Thailand, 1987 (DHS) 0.4 0.2 0.5 0.7 0.5 0.5 Trinidad and Tobago, 1987 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Tunisia, 1988 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Turkey, 1993 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Zambia, 1992 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Zambia, 1996–1997 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 Zimbabwe, 1988–1989 (DHS) 0.0 0.0 0.1 0.0 0.0 0.0 Zimbabwe, 1994 (DHS) 0.0 0.0 0.0 0.0 0.0 0.0 * Data refer to ages 15–44. † Data limited to Northeastern Brazil. ‡ Excludes the West Bank. Note: Data included here were generated at the request of EngenderHealth by Measure-DHS+ and by the Division of Reproductive Health, CDC. Supplement 2.4. Approximate annual incidence of male sterilization among partners of women of reproductive age who were ever in union, per 100 couples ever in union, by number of years prior to survey (cont’d.) No. of years prior to survey Country/year/source 5 4 3 2 1 5-year average (cont’d.) Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 55 © 2002 EngenderHealth Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence (cont’d.) % using sterilization Sterilization as a % using any % of overall Country/year Source method Total Male Female prevalence Notes Asia (cont’d.) Indonesia 1985 WP/98 Survey 38.5 1.6 0.4 1.2 4.2 1987 DHS 47.7 3.3 0.2 3.1 6.9 1991 DHS 49.7 3.3 0.6 2.7 6.6 1994 DHS 54.7 3.8 0.7 3.1 6.9 1997 DHS 57.4 3.4 0.4 3.0 5.9 Japan 1986 UN/ESA 64.3 9.9 1.6 8.3 15.4 1988 UN/ESA 56.3 4.2 0.9 3.3 7.5 1990 UN/ESA 58.0 5.7 NA NA 9.8 1994 UN/ESA 58.6 4.1 0.7 3.4 7.0 Korea, Republic of 1985 UN/ESA 70.4 40.5 8.9 31.6 57.5 4 1988 UN/ESA 77.3 48.2 11.0 37.2 62.4 4 1991 UN/ESA 79.4 47.3 12.0 35.3 59.6 4 Lao People’s Democratic Republic 1993 UN/ESA 18.6 5.1 NA 5.1 27.4 Malaysia 1988 UN/ESA 48.3 6.8 NA NA 14.1 6 Mongolia 1994 UN/ESA 60.7 0.9 0.3 0.6 1.5 Myanmar 1992 UN/ESA 16.8 5.5 1.8 3.7 32.7 Nepal 1986 WP/98 Survey 16.8 13.7 6.4 7.3 81.5 7 1991 WP/98 Survey 25.1 19.6 7.5 12.1 78.1 1996 DHS 28.5 17.5 5.4 12.1 61.4 Pakistan 1990–1991 DHS 11.8 3.5 Z 3.5 29.7 1994–1995 UN/ESA 17.8 5.0 Z 5.0 28.1 Philippines 1988 WP/98 Survey 36.2 11.4 0.4 11.0 31.5 4 1993 DHS 40.0 12.3 0.4 11.9 30.8 1995 WP/98 Survey 53.1 11.4 0.1 11.3 21.5 1996 WP/98 Survey 48.1 10.8 0.2 10.6 22.5 1998 DHS 46.5 10.4 0.1 10.3 22.4 Sri Lanka 1987 DHS 61.7 29.8 4.9 24.9 48.3 8 1993 UN/ESA 66.1 27.2 3.7 23.5 41.1 9 Thailand 1985 WP/98 Survey 59.0 23.2 3.7 19.5 39.3 1987 DHS 65.5 28.5 5.7 22.8 43.5 1993 UN/ESA 73.9 22.6 2.8 19.8 30.6 4 Vietnam 1988 WP/98 Survey 53.2 3.0 0.3 2.7 5.6 1994 WP/98 Nguyen 65.0 4.1 0.2 3.9 6.3 1997 DHS 75.3 6.8 0.5 6.3 9.0 (cont’d.) 56 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS © 2002 EngenderHealth Oceania Australia 1986 WP/98 Survey 76.1 38.1 10.4 27.7 50.1 10 New Zealand 1995 UN/ESA 74.9 33.0 18.0 15.0 44.1 10, 11 Papua New Guinea 1996 UN/ESA 25.9 7.8 0.2 7.6 30.1 Latin America and the Caribbean Antigua and Barbuda 1988 WP/98 CPS 52.6 11.0 NA 11.0 20.9 4 Bahamas 1988 WP/98 CPS 64.9 17.2 NA 17.2 26.5 4 Barbados 1988 UN/ESA 55.0 10.7 0.3 10.4 19.5 4 Belize 1985 WP/98 Survey 42.9 11.1 0.1 11.0 25.9 4 1991 CDC 46.7 18.7 NA 18.7 40.0 4 Bolivia 1989 WP/98 DHS 30.3 4.4 NA 4.4 14.5 1993–1994 WP/98 DHS 45.3 4.6 NA 4.6 10.2 1998 DHS 48.3 6.5 Z 6.5 13.5 Brazil 1986 DHS 65.8 27.6 0.8 26.8 41.9 4 1991 DHS 59.2 37.8 0.1 37.7 63.9 12 1996 DHS 76.7 42.7 2.6 40.1 55.7 Colombia 1986 DHS 64.8 18.7 0.4 18.3 28.9 1990 DHS 66.1 21.4 0.5 20.9 32.4 1995 DHS 72.2 26.4 0.7 25.7 36.6 Costa Rica 1986 CDC 69.0 17.2 0.5 16.7 24.9 1993 CDC 75.0 21.0 1.3 19.7 28.0 Cuba 1987 UN/ESA 70.0 22.0 NA 22.0 31.4 Dominica 1987 UN/ESA 49.8 12.6 NA 12.6 25.3 4 Dominican Republic 1986 WP/98 DHS 50.0 33.0 0.1 32.9 66.0 1991 WP/98 DHS 56.4 38.5 NA 38.5 68.3 1996 DHS 63.7 41.0 0.1 40.9 64.4 Ecuador 1987 WP/98 DHS 44.3 15.0 NA 15.0 33.9 1989 CDC 52.9 18.3 NA 18.3 34.6 1994 CDC 56.8 19.8 NA 19.8 34.9 1999 CDC 65.8 22.5 NA 22.5 34.2 Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence (cont’d.) % using sterilization Sterilization as a % using any % of overall Country/year Source method Total Male Female prevalence Notes (cont’d.) Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 57 © 2002 EngenderHealth Latin America and the Caribbean (cont’d.) El Salvador 1985 DHS 47.3 32.5 0.7 31.8 68.7 1988 CDC 47.1 30.2 0.6 29.6 64.1 4 1993 CDC 53.3 31.5 NA 31.5 59.1 4 1998 CDC 59.7 32.4 NA 32.4 54.3 4, 13 Guatemala 1987 DHS 23.2 11.3 0.9 10.4 48.7 4 1995 DHS 31.4 15.8 1.5 14.3 50.3 Haiti 1989 CDC 10.2 2.5 NA 2.5 24.5 1994–1995 DHS 18.0 3.1 NA 3.1 17.2 Honduras 1987 UN/ESA 40.6 12.8 0.2 12.6 31.5 4 1991–1992 UN/ESA 46.7 15.8 0.2 15.6 33.8 4 1996 CDC 50.0 18.1 NA 18.1 36.2 4 Jamaica 1989 CDC 54.6 13.6 NA 13.6 24.9 1993 CDC 62.0 12.5 NA 12.5 20.2 4 1997 CDC 66.0 12.3 NA 12.3 18.6 Mexico 1987 WP/98 DHS 52.7 19.4 0.8 18.6 36.8 1992 ENADID 63.1 27.9 1.0 26.9 44.2 1995 UN/ESA 66.5 27.3 NA NA 41.1 11 Nicaragua 1992–1993 CDC 48.7 18.8 0.3 18.5 38.6 1998 DHS 60.3 26.6 0.5 26.1 44.1 Panama 1984 CDC 58.8 33.5 0.4 33.1 57.0 4 Paraguay 1987 CDC 44.8 4.0 NA 4.0 8.9 4 1990 WP/98 DHS 48.4 7.4 NA 7.4 15.3 1995–1996 CDC 50.7 6.8 Z 6.8 13.4 14 1998 CDC 57.4 8.0 Z 8.0 13.9 4, 14 Peru 1986 WP/98 DHS 45.8 6.1 NA 6.1 13.3 1991–1992 DHS 59.0 8.0 0.1 7.9 13.6 1996 DHS 64.2 9.7 0.2 9.5 15.1 Puerto Rico 1995–1996 CDC 77.5 48.7 3.5 45.2 62.8 Saint Lucia 1988 WP/98 CPS 47.3 8.6 Z 8.6 18.2 4 Saint Vincent and the Grenadines 1988 WP/98 CPS 58.3 13.1 Z 13.1 22.5 4 Trinidad and Tobago 1987 DHS 52.7 8.4 0.2 8.2 15.9 North America Canada 1984 UN/ESA 73.1 43.5 12.9 30.6 59.5 15 1995 UN/ESA 75.2 46.0 16.2 29.8 61.2 11 Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence (cont’d.) % using sterilization Sterilization as a % using any % of overall Country/year Source method Total Male Female prevalence Notes (cont’d.) 58 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS © 2002 EngenderHealth North America (cont’d.) United States 1988 UN/ESA 74.3 36.3 12.9 23.4 48.9 4 1990 UN/ESA 70.7 37.3 13.6 23.7 52.8 4 1995 VHS 76.4 38.7 14.9 23.8 50.7 4 Western Europe Belgium 1991 UN/ESA 79.6 19.1 7.6 11.5 24.0 16, 17, 18 Denmark 1988 UN/ESA 78.0 10.0 5.0 5.0 12.8 4, 19 Finland 1989 WP/98 Survey 70.4 9.7 1.0 8.7 13.8 20 1994 WP/98 Survey 79.3 9.3 1.0 8.3 11.7 21 France 1988 WP/98 Survey 79.9 8.7 NA 8.7 10.9 15 1994 WP/98 Survey 75.1 4.9 0.3 4.6 6.5 Germany 1985 UN/ESA 77.9 12.4 2.1 10.3 15.9 4, 22 1992 UN/ESA 74.7 0.9 NA 0.9 1.2 23 Netherlands 1985 WP/98 Survey 72.0 14.0 NA NA 19.4 24 1988 WP/98 Survey 70.0 10.0 7.0 3.0 14.3 25 1993 WP/98 Survey 74.0 13.0 9.0 4.0 17.6 26 Norway 1988–1989 WP/98 Survey 75.5 14.7 4.3 10.4 19.5 27 Spain 1985 UN/ESA 59.4 4.6 0.3 4.3 7.7 15 Switzerland 1995 WP/98 Survey 81.9 22.0 8.3 13.7 26.9 10, 28 United Kingdom 1986 UN/ESA 81.0 31.0 16.0 15.0 38.3 29, 30 1989 WP/98 Survey 72.0 23.0 12.0 11.0 31.9 31 1993 UN/ESA 82.0 32.0 18.0 14.0 39.0 29, 30 Eastern Europe and Central Asia Azerbaijan 2001 CDC 55.4 1.2 Z 1.2 2.2 4 Belarus 1995 UN/ESA 50.4 0.8 Z 0.8 1.6 32 Czech Republic 1993 CDC 68.9 2.7 NA 2.7 3.9 4 Georgia 1999 CDC 40.5 1.6 Z 1.6 4.0 Hungary 1993 WP/98 Survey 84.4 5.1 NA NA 6.0 33 Kazakhstan 1995 DHS 59.1 0.7 NA 0.7 1.2 Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence (cont’d.) % using sterilization Sterilization as a % using any % of overall Country/year Source method Total Male Female prevalence Notes (cont’d.) Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 59 © 2002 EngenderHealth Eastern Europe and Central Asia (cont’d.) Kyrgyz Republic 1997 DHS 59.5 1.8 NA 1.8 3.0 Latvia 1995 WP/98 Survey 67.8 2.1 NA NA 3.1 15 Moldova 1997 CDC 73.7 3.4 NA 3.4 4.6 4 Romania 1993 CDC 57.3 1.4 NA 1.4 2.4 4 1999 CDC 63.8 2.5 Z 2.5 3.9 Russia 1996 CDC 71.8 2.0 NA 2.0 2.8 4, 34 Slovakia 1991 WP/98 UN 74.0 4.0 Z 4.0 5.4 4, 19 Slovenia 1989 WP/98 Survey 91.6 0.2 NA NA 0.2 4 Ukraine 1999 CDC 67.5 1.4 Z 1.4 2.1 Uzbekistan 1996 DHS 55.6 0.7 NA 0.7 1.3 Middle East Bahrain 1989 UN/ESA 53.4 7.1 NA 7.1 13.3 1, 35, 36 1995 UN/ESA 60.9 7.1 1.1 6.0 11.7 11, 35, 36 Iran 1992 UN/ESA 64.6 8.5 0.9 7.6 13.2 4 Iraq 1989 UN/ESA 13.7 1.4 NA 1.4 10.2 35, 36 Jordan 1985 CDC 26.5 4.9 Z 4.9 18.5 37, 38 1990 DHS 40.0 5.6 Z 5.6 14.0 1997 DHS 52.6 4.2 NA 4.2 8.0 Kuwait 1987 UN/ESA 34.6 2.0 NA 2.0 5.8 1, 36 Lebanon 1996 WP/98 PAPCHILD 61.0 4.2 NA 4.2 6.9 Oman 1988 UN/ESA 8.6 2.2 NA 2.2 25.6 1, 36 1995 UN/ESA 21.5 4.5 Z 4.5 20.9 11, 35, 36 Qatar 1987 UN/ESA 32.3 4.5 NA 4.5 13.9 1 Syria 1993 WP/98 PAPCHILD 39.6 2.2 Z 2.2 5.6 Turkey 1988 CDC 63.4 1.8 0.1 1.7 2.8 39 1993 DHS 62.6 2.9 Z 2.9 4.6 Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence (cont’d.) % using sterilization Sterilization as a % using any % of overall Country/year Source method Total Male Female prevalence Notes 60 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS (cont’d.) © 2002 EngenderHealth Middle East (cont’d.) United Arab Emirates 1995 UN/ESA 26.7 4.3 0.1 4.2 16.1 35, 36 Yemen 1991–1992 DHS 9.7 0.9 0.1 0.8 9.3 1997 DHS 20.8 1.5 0.1 1.4 7.2 35 Sub-Saharan Africa Benin 1996 DHS 16.4 0.4 NA 0.4 2.4 Botswana 1984 UN/ESA 27.8 1.5 Z 1.5 5.4 1988 DHS 33.0 4.6 0.3 4.3 13.9 Burkina Faso 1992–1993 DHS 24.9 0.2 Z 0.2 0.8 Burundi 1987 DHS 8.7 0.1 NA 0.1 1.1 Cameroon 1991 DHS 16.1 1.2 NA 1.2 7.5 1998 DHS 19.3 1.5 NA 1.5 7.8 Cape Verde 1998 CDC 52.9 12.8 Z 12.8 24.2 Central African Republic 1994–1995 DHS 14.8 0.4 NA 0.4 2.7 Chad 1996–1997 DHS 4.1 0.2 Z 0.2 4.9 Comoros 1996 DHS 21.0 2.8 NA 2.8 13.3 Congo, Democratic Republic of (Kinshasa) 1991 UN/ESA 8.0 0.3 0.1 0.2 3.8 Côte d’Ivoire 1994 DHS 11.4 0.2 NA 0.2 1.8 1998–1999 DHS 15.0 0.1 NA 0.1 0.6 Eritrea 1995–1996 DHS 8.0 0.3 NA 0.3 3.8 Ethiopia 1990 UN/ESA 4.3 0.2 Z 0.2 4.7 40, 41 Gambia 1990 UN/ESA 11.8 0.4 Z 0.4 3.4 Ghana 1988 DHS 12.9 1.0 NA 1.0 7.8 1993 DHS 20.3 0.9 NA 0.9 4.4 1995 WP/98 Survey 28.0 2.0 NA NA 7.1 1998 DHS 22.0 1.3 Z 1.3 5.9 Guinea 1992–1993 UN 1.7 0.1 Z 0.1 5.9 Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence (cont’d.) % using sterilization Sterilization as a % using any % of overall Country/year Source method Total Male Female prevalence Notes Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 61 (cont’d.) © 2002 EngenderHealth Sub-Saharan Africa (cont’d.) Kenya 1984 UN/ESA 17.0 2.6 Z 2.6 15.3 1989 DHS 26.9 4.7 Z 4.7 17.5 1993 DHS 32.7 5.5 NA 5.5 16.8 1998 DHS 39.0 6.2 NA 6.2 15.9 Lesotho 1991–1992 UN/ESA 23.2 1.4 Z 1.4 6.0 Liberia 1986 DHS 6.4 1.1 NA 1.1 17.2 Madagascar 1992 DHS 16.7 0.9 Z 0.9 5.4 1997 DHS 19.4 1.0 Z 1.0 5.2 Malawi 1992 DHS 13.0 1.7 Z 1.7 13.1 1996 DHS 21.9 2.5 NA 2.5 11.4 Mali 1987 DHS 4.7 0.1 NA 0.1 2.1 1995–1996 DHS 6.7 0.3 NA 0.3 4.5 Mauritius 1985 CDC 75.3 4.7 NA 4.7 6.2 1991 CDC 74.7 7.2 NA 7.2 9.6 4 Mozambique 1997 DHS 5.6 0.7 NA 0.7 12.5 Namibia 1989 WP/98 Survey 26.4 6.1 0.1 6.0 23.1 1 1992 DHS 28.9 7.6 0.2 7.4 26.3 Niger 1992 DHS 4.4 0.1 NA 0.1 2.3 1998 DHS 8.2 0.1 NA 0.1 1.2 Nigeria 1986 DHS 6.1 0.1 NA 0.1 1.6 42.0 1990 DHS 6.0 0.3 NA 0.3 5.0 Réunion 1990 WP/98 Survey 72.9 5.1 Z 5.1 7.0 Rwanda 1983 UN/ESA 10.1 Z Z Z Z 1992 DHS 21.2 0.7 NA 0.7 3.3 43 Senegal 1992–1993 DHS 7.5 0.4 NA 0.4 5.3 1997 DHS 12.9 0.5 NA 0.5 3.9 South Africa 1988 UN/ESA 49.7 9.4 1.4 8.0 18.9 1 1998 DHS 56.3 17.9 2.1 15.8 32.0 Sudan 1989–1990 DHS 8.7 0.8 NA 0.8 9.2 Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence (cont’d.) % using sterilization Sterilization as a % using any % of overall Country/year Source method Total Male Female prevalence Notes 62 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS (cont’d.) © 2002 EngenderHealth Sub-Saharan Africa (cont’d.) Sudan (Northern) 1992–1993 UN/ESA 8.3 0.9 Z 0.9 10.8 Swaziland 1988 CDC 20.8 5.0 0.3 4.7 24.0 44 Tanzania 1988 WP/98 USAID 7.0 NA NA NA NA 4 1991–1992 DHS 10.4 1.6 Z 1.6 15.4 1994 DHS-KAP 20.4 2.0 NA 2.0 9.8 1996 DHS 18.4 1.9 NA 1.9 10.3 Togo 1988 DHS 33.9 0.6 NA 0.6 1.8 1998 DHS 23.5 0.4 NA 0.4 1.7 Uganda 1988–1989 DHS 4.9 0.8 NA 0.8 16.3 1995 DHS 14.8 1.4 NA 1.4 9.5 Zambia 1992 DHS 15.2 2.1 Z 2.1 13.8 1996 DHS 25.9 2.0 Z 2.0 7.7 Zimbabwe 1988–1989 DHS 43.1 2.5 0.2 2.3 5.8 1994 DHS 48.1 2.5 0.2 2.3 5.2 North Africa Algeria 1986–1987 UN/ESA 35.5 1.3 Z 1.3 3.7 1992 WP 98/PAPCHILD 50.9 1.1 Z 1.1 2.2 Egypt 1984 WP/98 CPS 30.3 1.5 NA 1.5 5.0 1988 DHS 37.8 1.5 Z 1.5 4.0 1992 DHS 47.1 1.1 NA 1.1 2.3 1995–1996 DHS 47.9 1.1 NA 1.1 2.3 Libya 1995 WP/98 PAPCHILD 45.2 3.8 NA 3.8 8.4 Morocco 1987 DHS 35.9 2.2 NA 2.2 6.1 1992 DHS 41.5 3.0 NA 3.0 7.2 1995 DHS 50.3 4.3 NA 4.3 8.5 Tunisia 1988 DHS 49.8 11.5 NA 11.5 23.1 1994 WP/98 PAPCHILD 59.7 12.6 NA 12.6 21.1 Source notes: CDC � data from a maternal health, contraceptive prevalence or reproductive health survey conducted by the Division of Reproductive Health, U.S. Centers for Disease Control and Prevention (CDC). CPS � data from Contraceptive Prevalence Survey program data (either Westinghouse Health Systems or the CDC). DHS � Demographic and Health Survey data. ENADID � Encuesta Nacional de la Dinámica Demográfica de 1992. KAP � knowledge, attitudes, and practices survey. Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence (cont’d.) % using sterilization Sterilization as a % using any % of overall Country/year Source method Total Male Female prevalence Notes Chapter 2 • STERILIZATION INCIDENCE AND PREVALENCE 63 (cont’d.) © 2002 EngenderHealth Source notes: (cont’d.) PAPCHILD � data from the Pan Arab Project for Child Development of the League of Arab States. PC � data from the Population Council, derived from service statistics, sometimes with an estimate for private-sector contraceptive use. Survey � data taken from a nationwide survey conducted by a national government or independent organization that is not a contraceptive prevalence survey or survey conducted as part of the DHS or World Fertility Survey. UN/ESA � data from the United Nations (UN) Department of Economic and Social Affairs, Population Division, as published in UN Population Division, 1999. USAID � data from the U.S. Agency for International Development. VHS � U.S. Vital and Health Statistics. WP/98 � data taken from the U.S. Bureau of the Census 1999, World Population Profile, 1998. WP/98 Nguyen = data from Nguyen et al. (1996), as reported in U.S. Bureau of the Census, 1999. NA � data not available. Z � negligible (�0.1%). Explanatory notes: Supplement 2.5. Percentage of women of reproductive age currently in union who are using contraception, percentage who are using sterilization, by type, and share of sterilization as percentage of overall prevalence (cont’d.) 64 CONTRACEPTIVE STERILIZATION: GLOBAL ISSUES AND TRENDS 1. Data refer to ages �50. 2. Represents women aged 10–49. 3. Data refer to all women aged 15–49, regardless of marital status. 4. Data refer to women aged 15–44. 5. Data refer to women aged 13–49. 6. Data refer to peninsular Malaysia only. 7. Data refer to women aged 15–50. 8. Data exclude northern and eastern provinces. 9. Coverage is not national. 10. Data refer to women aged 20–49. 11. Preliminary or provisional data. 12. Data are limited to the population of Northeastern Brazil. 13. Male sterilization rates represent �0.7%. 14. Data on contraceptive prevalence do not include use of herbal medicines known as “yuyos.” 15. Data refer to women aged 18–49. 16. Data refer to women aged 20–40. 17. Data refer to the Flemish population only. 18. Data include individuals sterilized for noncontraceptive purposes. 19. Data refer to all sexually active women. 20. Data refer to women aged 21–49. 21. Data refer to women aged 18–44. 22. Data refer to the Federal Republic of Germany only. 23. Data refer to women aged 20–39. 24. Data refer to women aged 21–37. 25. Data refer to women aged 18–37. 26. Data refer to women aged 18–42. 27. Data are for women who were born in 1945, 1950, 1965, and 1968 only. These women were 20, 23, 28, and 43 at the time of the sur- vey. 28. From unpublished tables, Swiss Federal Statistical Office, Family and Fertility Survey 1994–1995. 29. Data refer to women aged 16–49. 30. Data refer to Great Britain, and do not include Northern Ireland. 31. Data refer to all women aged 18–44. 32. Data refer to women aged 18–34. 33. Data refer to women aged 18–41. 34. Survey was limited to three sites (Ivanovo, Yekaterinburg, and Perm); the percentages noted here represent averages. 35. Adjusted from source to exclude breastfeeding. 36. Data refer to nationals only. 37. Data refer to women aged 17–51. 38. Excludes the West Bank. 39. The total prevalence rate refers to currently married women, while data by method are based on exposed women only. 40. Refers to ever-married women. 41. Excludes Eritrea, Tigray, Asseb, Ogaden, parts of Gondar and Wello, and nomadic populations. 42. Data refer to Ondo State only. 43. Data refer to women aged 15–50. 44. Data refer to ever-married women and unmarried women who have had a child. © 2002 EngenderHealth

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