Georgia Reproductive Health Survey 2010-2011

Publication date: 2012

F I N A L R E P O R T Reproductive Health Survey Georgia 2010 Reproductive Health Survey Georgia 2010 F I N A L R E P O R T National Center for Disease Control and Public Health (NCDC) Ministry of Labor, Health, and Social Affairs (MoLHSA) National Statistics Office of Georgia TBILISI, GEORGIA Division of Reproductive Health, Centers for Disease Control and Prevention (DRH/CDC) ATLANTA, GEORGIA USA United Nations Population Fund (UNFPA) United States Agency for International Development (USAID) The United Nations Children’s Fund (UNICEF) 2012 FINAL REPORT i Authors and Contributors: National Center for Disease Control and Public Health: M. Butsashvili - RHS Scientific Committee Director G. Kandelaki L. Sturua M. Shakh-Nazarova N. Mebonia N. Avaliani Panel of Experts: Z. Bokhua T. Asatiani Z. Sinauridze G. Tsuladze K. Chkhatarashvili J. Kristesashvili G. Tsagareishvili Division of Reproductive Health, Centers for Disease Control and Prevention: Florina Serbanescu Vasili Egnatashvili Alicia Ruiz Danielle Suchdev Mary Goodwin Editor in Chief - John Ross Cover: Openwork Buckle: Sheuba, 2nd-3rd centuries AD, bronze. (Artwork preserved at the Treasury of the Georgian National Museum) © Georgian National Museum (GNM); www.museum.ge This report is funded by UNFPA and UNICEF Joint Project “Support to Georgian RH Survey, 2010” The Preliminary Report of the survey was funded by the United States Agency for International Development (USAID) agreement with the Division of Reproductive Health of the Centers for Disease Control and Prevention and USAID Contract No. HRN-C-00-97-0019-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of UNFPA, UNICEF and USAID. Additional information about this report may be obtained from the National Center for Disease Control and Public Health (NCDC): 9, M. Asatiani str., Tbilisi 0177, Georgia Tel. :(995 32) 239 89 46 Fax : (995 32) 231 14 85 e-mail: ncdc@ncdc.ge The report was printed by: Vesta, Ltd (Tbilisi, Georgia) REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 2ii This report presents the findings of the 2010 Georgia Reproductive Health Survey (GERHS10). The GERHS10 is the third nationally representative survey to collect comprehensive information on reproductive health status and utilization of reproductive health and maternal and child health care services in the country. The first two surveys took place in 1999 and 2005 and provided a baseline and follow-up for numerous and essential health indicators that can track changes in family planning, maternal and child health, and other reproductive health efforts. Results showing low usage of modern contraception and high rates of unintended pregnancies were instrumental in designing and implementing new health strategies and programs and promoting health care reforms. Since then, maternal and child health services were strengthened, family planning supply efforts have been intensified, the number of sites and physicians providing family planning services has been expanded and reproductive health information, education and communication activities were strengthened. The efforts to improve the health of women, infants and children are at the core of the health care reforms in Georgia. The National Healthcare Strategy 2011-2015 “Access to Quality Healthcare” targets enhancement of maternal and child health services. For these efforts to be successful, public health professionals have to identify the needs of women and children, to design and implement appropriate interventions, and to monitor and evaluate those interventions. The Ministry of Labor, Health and Social Affairs (MoLHSA) is directly responsible for implementing reproductive health reforms, including: compliancy with international standards and treaties in the health sector; provision and access of high quality healthcare for mothers and children; establishment of an international standard infrastructure for health care services; and maternal and child death reviews to help design the most appropriate evidenced-based preventive measures. The surveys provide the MoLHSA with a much needed ability to track progress in program outcomes, formulate targeted interventions, monitor the national development programs, and report on progress toward the Millennium Development Goals (MDGs). By making available appropriate national and region specific data on reproductive health status and service delivery and enhancing the ability of local organizations to collect, analyze and disseminate such information, these three surveys brought a tremendous contribution to fostering collaboration among governmental agencies (MoLHSA, National Reproductive Health Council, National Center for Disease Control and Public Health), international donors (USAID, UNFPA and UNICEF) and technical experts (Centers for Disease Control and Prevention), whose common goal was to inform policies and advance appropriately designed reproductive health sector reforms. It is my pleasure and privilege to express my gratitude to these organizations for their dedication and allocation of time and resources. To my staff and all of the individuals involved in bringing this work to successful completion, my deepest thanks for your invaluable contributions. Preface Zurab Tchiaberashvili Minister of Labor, Health and Social Affairs of Georgia FINAL REPORT iii REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 4iv The 2010 Georgian Reproductive Health Survey (GERHS10) was conducted by the Georgian Center for Disease Control and Public Health (NCDC) in collaboration with the Georgian Ministry of Labor, Health, and Social Affairs (MoLHSA) with the support of United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF) and United States Agency for International Development (USAID). The Division of Reproductive Health of the United States Centers for Disease Control and Prevention (CDC/DRH) provided technical assistance on the survey design, questionnaire development, training, data processing and summary report writing. The NCDC and CDC/DRH wish to express their appreciation to those involved in the implementation of the 2010 Georgian Reproductive Health Survey and the preparation of this report. Particular thanks go to the Ministry of Labor, Health and Social Affairs for its chairmanship of the steering committee and the National Reproductive Health Council, chaired by Ms. Sandra Elisabeth Roelofs, The First Lady of Georgia, for its leadership in reproductive health in the country. Special thanks are extended to Mr. John Ross, Editor-in-Chief of the final report of the survey, and the team of national experts who have contributed to the development of the report. Our special thanks go to the United States Agency for International Development (USAID) who provided generous financial resources for implementation of the study and developed over the years the NCDC’s capacity to conduct population-based health studies; the technical assistance of DRH/CDC and the preparation of the summary survey report were supported by USAID. We are particularly grateful to Tamara Sirbiladze, Senior Health and Infectious Diseases Advisor, Jeri Dible, Director, Health and Social Development Office, Jonathan Conley, Mission Director, and Nana Chkonia, Programme Assistant, USAID Caucasus, Georgia — for their continuous support of NCDC and DRH/CDC and the catalyst contribution to the study. We are very grateful for the contribution provided by the United Nations Population Fund (UNFPA) and United Nations Children’s Fund (UNICEF), whose generous funding and technical expertise were essential in survey planning, fieldwork activities, and dissemination of the results. Particularly, we would like to acknowledge the UNFPA staff in Georgia — Tamar Khomasuridze, UNFPA Georgia Assistant Representative, Lela Bakradze, Programme Analyst, and Marina Tsintsadze, Admin/ Finance Associate and the UNICEF staff — Roeland Monasch, UNICEF Representative in Georgia and Tinatin Baum, Social Policy Specialist — for their assistance in design, planning and financial management. Most of all, we would like to thank the households whose participation made it possible to obtain the reliable information collected in the survey and advanced our knowledge of women’s reproductive health in Georgia. We are grateful to our highly skilled interviewers, supervisors, and data entry personnel for their commitment, discipline, and dedication to the project. This report was prepared by the NCDC with the invaluable guidance and contributions of many individuals, both inside and outside NCDC. Acknowledgements FINAL REPORT v REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 6vi Georgia is a country with a strong cultural identity. Ethnic Georgians represent 84% of the total popu- lation, with Armenians and Azeri the largest ethnic minorities. Women’s health in Georgia is strongly in- fluenced by cultural, historical, and socioeconomic factors. The previous Communist regime, notori- ous for its lack of support for family planning, had a profound impact on women and their reproductive health. Due to a significant decline in socioeconomic conditions in the 1990s, the health of the population deteriorated seriously. In response to the collapse of the publicly-supported hospital-based health system, Georgia initiated an extensive health sector reform in the mid-1990s. The process was designed to address all aspects of the health-care sector and to emphasize quality of care, improved access, efficiency, and reha- bilitation of the primary health care system. Decen- tralization and, since 2007, privatization, have been major components of the reform process. The privati- zation of hospitals called for full transfer of ownership to the private sector. Primary health care services are also in various stages of privatization. Despite the pro- gress made during the last decade, health care expen- ditures comprise a decreasing portion of public ex- penditures, resulting in the underfunding of medical facilities, as well as family planning and reproductive health services. Over the past several years, the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA), and other multi- lateral and bilateral donors have invested resources to improve access to family planning and other re- productive health services in Georgia. Through funds provided by USAID and UNFPA, a series of nationwide Reproductive Health Surveys (RHS) was conducted in 1999, 2005 and 2010. These surveys were developed by the U.S. Centers for Disease Control and Preven- tion (CDC), in response to the need to obtain detailed reproductive, maternal and child health indicators, with international comparisons. They draw upon CDC’s expertise with survey methodologies in the U.S. combined with its international experience, regard- ing family planning, maternal and child health, and women’s health. In many counties, including Georgia, these surveys have been the main source of popula- tion-based data for reproductive health policies and planning. The demographic and reproductive health indicators provided by the surveys serve multiple pur- poses: to examine health trends, set targets for im- provement, allocate resources, monitor performance, measure program achievements, prioritize activities, guide research, and allow global comparisons in re- productive health. A major purpose of the surveys in Georgia was to pro- duce national and sub-national estimates of factors related to pregnancy and fertility, such as sexual activ- ity and contraceptive use; use of abortion and other medical services; maternal and infant health, and women’s health. The first RHS was conducted in Geor- gia in 1999; a new cycle was implemented in 2005, fol- lowed by the most recent cycle, implemented in 2010. As with the first two rounds, the Georgian Ministry of Labor, Health and Social Affairs (MoLHSA) conducted the survey in collaboration with the Georgian National Center for Disease Control (NCDC). The CDC provided technical assistance with the survey design, sampling, questionnaire development, training, data processing and analysis to all three surveys through funding from USAID. Local costs were primarily covered by UNFPA and UNICEF. All three surveys employed large, nationally repre- sentative, probability samples and collected informa- tion on a wide range of health related topics from women aged 15–44 who were interviewed in their homes. The samples were selected in such a man- ner as to allow separate urban and rural, as well as regional-level estimates. In the most recent Georgian RHS (GERHS10), 13,363 households were visited and 6,292 women were successfully interviewed, yield- ing a response rate of 99%. Virtually all respondents who were selected to participate and who could be reached agreed to be interviewed. Several findings of the GERHS10 are highlighted be- low. GERHS10 Overview • Set within the context of overall social and economic development in Georgia, the aim of the 2010 survey was to obtain national and regional esti- mates of basic demographic and reproductive health indicators and compare them to previous RHS results. • In response to the decentralization of health activities, the survey employed a sample design that produced estimates for 11 regions of the country and for rural vs. urban sectors, to enable key stakeholders to assess reproductive health indicators at the subna- tional level. • The survey employed a stratified multistage sampling design, similar to the design used in the 1999 and 2005 cycles. Characteristics of Households and Respondents • While the majority of households had tap wa- ter in their residence or yard (76%) there is a great dis- parity between urban and rural households (96% vs. 55%). Overall, 98% of urban and 88% of rural house- Executive Summary FINAL REPORT vii holds in Georgia use improved sources of drinking wa- ter (tap water and water from protected wells). • Overall, 96% of urban households and 71% of rural households using improved sanitation facilities. • The distribution of the Georgian popula- tion across the wealth quintiles varied greatly by residence; almost three in four (74%) of urban house- holds were classified in the two highest wealth quin- tiles while only 3% of rural households were in these wealth groups. • The majority of respondents were of Geor- gian ethnicity (87%), followed by Azeri (5%) Armenian (5%) and other ethnicities (3%). Respondents belong- ing to minority ethnic groups were more likely to live in rural areas than in urban areas. • Eighty two percent of women were Georgian Orthodox and 11% were Muslim. • Educational attainment is wide-spread in Georgia with 77% of women reporting at least com- pletion of secondary education. Thirty-nine percent of women had gone on to complete university or post- graduate education. Tbilisi residents reported much higher educational attainment than in other regions: 60% of respondents have undergone university train- ing while only 13% did not complete secondary educa- tion. • Boys and girls are equal in the percent enter- ing grade 1 and in the percent transitioning from pri- mary to secondary school. • Most women (79%) reported not working outside of the house, a situation that was even more pronounced in rural areas (87%) where job availability is very low. Marriage and Fertility • Nearly 60% of women in the sample (aged 15-44) were married or in consensual unions, 7% were divorced or separated, and 34% had never been mar- ried. • The TFR (total fertility rate) calculated from the 2010 survey, of 2.0 births per woman (95%CI=1.9– 2.1) for the period 2007–2010, is the highest survey- based TFR ever reported for Georgia. It is 25% higher than the TFR of 1.6 births per woman (95%CI=1.4–1.7) observed for 2002–2005. • Traditionally, Georgian women initiate and complete childbearing at an early age, as reflected in very high age-specific fertility rates for young women. The highest fertility levels were at ages 20-24 and 25- 29, accounting for 36% and 29%, respectively, of the TFR. Fertility among adolescent women (39 births per 1,000 women aged 15–19) contributed to only 10% of the TFR. Fertility among women aged 30–34 was the third-highest ASFR, contributing 15% of the TFR. • Compared to the 2005 survey, age-specific fertility rates increased in all but one age group (ado- lescent women) suggesting a gradual transition to fer- tility postponement in Georgia. • Generally, peak fertility occurred at ages 25– 29 among women with the highest educational attain- ment, whereas at lower educational levels it occurred at ages 20–24. This partially reflects differences in the age at marriage. Fertility rates of ethnic minorities, particularly among the Azeri group (2.4 children per woman) were higher than those of the Georgians, the major ethnic group (2.0 children per woman), due to much higher ASFRs among Azeri women aged 15–24. Pregnancy Intention Status • Most women who have been pregnant in the past 5 years reported the last pregnancy as planned and only 36% said they had an unplanned pregnan- cy—11% mistimed and 26% unwanted. This compares to the higher levels of 51% of women reporting their last pregnancy as unplanned in 2005 and 59% in 1999. Mistimed pregnancies represented a larger share of unplanned pregnancies in 2010 than in previous sur- veys, suggesting that more women than in the past want to postpone rather than end childbearing. • Nearly all women whose last pregnancy end- ed in induced abortion reported that their concep- tions were unplanned (96%). • Thirty-five percent of women currently mar- ried or in consensual union wanted more children, compared to 25% in 1999 (a 40% increase). This trend was consistent regardless of the number of living chil- dren. Particularly notable was the relatively high pro- portion of women with two or more children who said in 2010 that they wanted more children (21% com- pared to only 12% in 1999). • The desire to have more children was very high among young women (89% at ages 15-19 and 73% at ages 20–24), dropping to 47% at ages 25-29 and declining further among women aged 30 or older. • Between 1999 and 2010, there were nota- ble changes in the timing of wanting a(another) child, according to the current age. Among the youngest women, the proportion who wanted a child within two years declined by 29% (from 61% to 44%); the percent saying they wanted no more fell from 14% to 7%. Similar declines occurred in each older age group. • Among fecund married women who had had two or more children, the majority (68%) were ready to terminate childbearing. This pattern is similar to the one documented in the 1999 and 2005 surveys, but in 2010 fewer women with two or more children said they did not want to have a(another) child. Induced Abortion • The survey data allow for calculation of the total induced abortion rate (TIAR), which gives the REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 8viii number of abortions a woman would have in her life- time under the current age specific induced abortion rates (ASIARs). Previous RHS surveys showed a steep increase in the TIAR after 1990, when the USSR broke up, with a peak of 3.7 abortions per woman in 1997– 1999. The abortion rate declined gradually to 3.1 abortions per woman (95%CI= 2.9–3.4 abortions per woman) in 2002–2005. Between 2005 and 2010, the abortion rate dropped significantly to 1.6 abortions per woman (95%CI= 1.5–1.8 abortions per woman), a 48% decline from 3.1, or 57% from 3.7. • The estimated TIAR for the period 2007–2010 according to official sources was only 0.9 abortions per woman (44% lower than the rate documented in the survey but an improvement from over 80% under- reporting documented in 1999 and 2005). • More than one-half of Georgian women ob- taining abortions in 2007–2010 were aged 25–29 (102 abortions per 1,000 women) and 30–34 (83 abortions per 1,000 women). The third highest age specific abor- tion rate, contributing to 25% of the TIAR, occurred among women aged 35–39. The ASIARs were signifi- cantly higher than ASFRs only among women aged 30 or older, suggesting that most Georgian women con- tinue to achieve their desired family size before age 30 after which, in the event of having unplanned preg- nancies, they are more likely to end them in induced abortions. • The survey-based estimate of the abortion- to-live–birth ratio changed from to 2.1 induced abor- tions for each live birth (2.1:1) in 1999, to 1.5:1 in 2005, and to 0.8:1 in 1999. Thus, birth experience surpassed abortion experience for the first time since survey-based reports were collected. This was mainly achieved by a combination of increases in fertility and declines in abortion at ages 20–24, 25–29, and 30–34, which contribute the most to both total fertility and total abortion rates. • Higher abortion rates among rural women, less educated women, and women of Azeri descent suggest that access to services is unequal and that Georgia’s family planning program needs to expand its reach to disadvantaged subgroups. • The main reasons given for choosing abortion included: desire to stop childbearing (51%), desire to space the next birth (18%), and socioeconomic cir- cumstances that prevent the family from supporting another child (20%). • Of all abortions reported by survey respond- ents during the past 5 years, 71% were mini-abortions; this is sharply up from 40% in 1999 and 56% in 2005. • Most induced abortions occurring in 2005 or later were performed in gynecological wards (56%); 42% were performed in ambulatory clinics, such as women’s consultation clinics (WCCs); and 2% were performed outside medical facilities. Regarding fees, the average abortion payment did not vary by type of medical facility. At the time of the survey, mean charg- es for an abortion procedure were about US$29.00, which represents an increase of 65% compared to the average cost in 2005. • Few family planning services are received around the time of having an abortion. While one in three (33%) respondents with a history of abortion in 2005-2010 reported receiving contraceptive coun- seling before or/and after the abortion; only 6.6% of women (20% of women who received counseling) received a contraceptive method to prevent future unintended pregnancies; and an additional 7.4% of women received a prescription for contraceptive sup- plies (22% of all women counseled). • Receipt of contraceptive information in 2010 was however more than twice the level documented in the 1999 survey (33% vs. 15%). Actual receipt of a contraceptive method or prescription for a method almost tripled, from 5% to 14%, both rather low rates but improving. Maternal and Child Health Services • Use of prenatal care was almost universal: 98% of pregnant women received at least one prena- tal examination. Initiation of prenatal care in the first trimester was more common in urban areas than in rural areas (93% vs. 86%) and was most widespread in Tbilisi (94%). • Ninety percent of women received at least 4 prenatal care visits and this was more common among women in urban areas (95%) than in rural areas (86%). • One in two women received most of their prenatal care from women’s consultation clinics (49%) and 44% received their care from regional maternity hospitals. Only 7% of the women received care from primary care clinics or family medicine centers. • In both 1999 and 2005, about one in twelve births (8%) was delivered at home, the majority with- out skilled attendance; in 2010 only 2% of births were delivered at home. Home births were slightly higher among Azeri women (5%), but in clear decline com- pared to the level of 40% home deliveries among this ethnic group in 2005. • Eighty four percent of newborns received a well-baby checkup but only 23% of women reported receiving postpartum care in 2010. Use of postpartum care was also low in 2005 (23%), indicating that this service is still vastly underutilized in Georgia. • Virtually all (97%) babies born alive in 2005– 2010 were registered, according to the mother; how- ever, registered births ranged from a low of 92% in the region of Kakheti to a high of 99% in the region of Samtskhe-Javakheti. Home births were least likely to be registered (67%). FINAL REPORT ix Breastfeeding • The majority (87%) of infants born within the five years leading up to the 2010 survey had been breastfed, virtually unchanged compared to 1999 and 2005. Georgian women reported lower rates of breastfeeding than women of other ethnicities. • Since the 1999 survey, the proportion of ba- bies who were breastfed within the first hour after birth increased by 4 times (from 5% in 1999 to 10% in 2005 and 20% in 2010), while the proportion of those who received breast milk 1–23 hours after birth dou- bled, from 28% to 55%. • On average, the duration of any breastfeed- ing was 12.1 months, 2 months longer from the 10.1 months recorded in the 2005 survey. The duration of full breastfeeding (either exclusive breastfeeding or predominantly breastfeeding) was 4.1 months, longer than the 3.7 months documented in the 1999 and 2005 surveys. Perhaps the most important gain was in the duration of exclusive breastfeeding (only breast milk), which doubled from the level documented in the 1999 survey (from 1.5 to 3 months). Perinatal & Childhood Mortality • Of all births that occurred during the five years prior to the survey, 8 per 1,000 were stillbirths. The stillbirth rate was highest among women who did not receive any prenatal care (50 stillbirths per 1,000), women who suffered complications during their preg- nancies (34 stillbirths per 1,000), women who had prolonged labor (30 stillbirths per 1,000) and women who delivered after age 35 (11 stillbirths per 1,000). • The infant mortality rate, the rate at which babies less than one year of age die, has continued to decline steadily, from 41.6 per 1,000 live births in 1995–1999 to 21.1 per 1,000 live births in 2000–2004 and to 14.1 per 1,000 live births in 2005-2009. The ne- onatal mortality rate (deaths in the first month of life) went down from 25.4 per 1,000 live births in 1995– 1999 to 16.8 per 1,000 live births in 2000–2004 and even lower to 9.5 per 1,000 live births in 2005-2009. • A two-thirds reduction in mortality before age five between 1990 and 2015 is centrally formu- lated in the Millennium Development Goal 4 (MDG- 4). This “under-5 mortality rate” dropped from 45.3 per 1,000 births in 1995–1999 to 25.0 in 2000–2004 and 16.4 in 2005-2009—a nearly 64% decline. Thus, according to the survey estimates, Georgia essentially achieved MDG-4 by 2010. • Child survival in Georgia improved substan- tially over the past 15 years, mainly through signifi- cant reductions in neonatal and post-neonatal mortal- ity. Given that neonatal deaths continue to account for most of infant mortality and 58% of under-5 deaths in Georgia, further reductions in child mortality will de- pend heavily on continuing the improvements in sur- vival during the neonatal period. Contraception Awareness • Virtually all respondents (96%) had heard of at least one modern method—particularly the con- dom (94%), IUD (87%), and oral contraceptives (81%). However, only 39% of women had heard of tubal liga- tion and few (4%) had heard of vasectomy. • For each contraceptive method, there is a considerable gap between awareness of the method and knowledge of how that procedure or product is used. • Most women do not have correct knowledge about how effective the modern methods of contra- ception are; while 30% of women correctly stated that IUDs are very effective in preventing pregnancy, only 16% believed that contraceptive sterilization is very effective. The majority of women incorrectly thought that pills were not very effective. Contraceptive Use • Among all women aged 15–44, 32% were currently using a contraceptive method, including 21% who were using supplied methods (condoms, IUDs, oral contraceptives, tubal ligation, and spermi- cides). • Among married women aged 15-44 more than half (53%) were currently using contraception, in- cluding 35% using modern methods. The use of mod- ern contraceptive methods rose sharply, from 20% in 1999 to 35% in 2010. For the first time, the prevalence of modern methods exceeded the prevalence of tra- ditional methods, which declined. As a result the con- traceptive prevalence rate (CPR) for married women increased from 41% in 1999 to 45% in 2005 and 53% in 2010. • Among all current contraceptive users, 26% were using the condom (14% out of 53%), followed by 25% using the IUD (13% out of 53%), 21% using withdrawal (11% out of 53%), 13% using periodic ab- stinence (7% out of 53%), 7% using the pill (4% out of 53%), 5% using tubal ligation (2.9% out of 53%), and 3% using spermicides (1.5% out of 53%). • Between 1999 and 2010, condom use among couples increased 2.5 times (from 6% to 14%) and IUD use increased from 10% to 13%, becoming the first and second most used methods, respectively. With- drawal and the rhythm method, the leading methods in 1999, became the third and fourth most commonly used methods in 2010. Pill use, still very low, increased from 2% in 1999 to 4% in 2010, and tubal ligation in- creases from 2% to 3%. • Health facilities including primarily health care clinics/centers, women’s consultation clinics and city or regional hospitals with gynecology wards were the main sources of modern contraceptive methods, REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 10x supplying 50% of users. Commercial sales, specifically through pharmacies, were the second largest source of modern contraceptive supplies (45%). Nearly 5% of users obtained their method from “other” sources, such as their partners, friends and relatives, and the open market. Potential Demand for Contraception • Almost two-thirds (65%) of married women have a potential demand for contraception, including 52% who already use a method and 12% whose de- mand has yet to be satisfied (i.e. have an unmet need for some contraceptive method). The unmet need for contraception among married women in 2010 is half the level documented in 1999 (12% vs. 24%), mostly as a result of increased use of modern methods. Need rises with rural residence, low education, larger fami- lies, and poor wealth quintiles. Most need is for limit- ing rather than spacing, in a 2 to 1 ratio. • Among current users (52%), 18% use tradi- tional methods, which are subject to high failure rates and consequent abortions. When these are added to the unmet need group (12%) the total need for mod- ern methods is 30%, nearly a third of all married wom- en. • Among married women, besides the 52% who use a method; 13% are currently pregnant or postpartum, 9% are infecund, 6% are not sexually ac- tive, and 8% are seeking to become pregnant, totaling 88%. The other 12% have unmet need as noted, or 30% including traditional method users. (In addition, some who are postpartum will soon be exposed to an unwanted conception.) Contraceptive Counseling • Family planning counseling in Georgia is mostly available only through specialized facilities, is mostly offered as part of postpartum or post-abortion care, and seldom includes distribution of supplies or prescription for supplies. Thus, Georgia has a great need for new policies that will expand the scope of contraceptive counseling and allow its integration with other reproductive health services at the primary care level. • Most family planning services in Georgia are provided by Ob/Gyns and “reproductologists” (phy- sicians who have received extra training related to reproductive issues) who traditionally have little ex- pertise in providing family planning client-oriented counseling. An important component of the newly implemented reproductive health strategy in Georgia is to train health professionals to provide family plan- ning counseling at any point of contact with medical care, including primary health care services. • Most respondents were advised by a gynecol- ogist or reproductologist to use their current or most recent modern method (56%). Women who did not receive medical advice started using their last method at the partner’s suggestion (23%), at their own coun- sel (9%), at the suggestion of friend (5%), or at the suggestion of a relative (4%), bypassing any potential family planning counseling. In only 1% of cases was the choice of the method made at the suggestion of a pharmacist. • During provider-client interactions, 64% of women received general information about alterna- tive contraceptive methods in 2010, compared to only 32% in 1999; 59% were counseled about the effec- tiveness of the chosen method in 2010 compared to only 31% in 1999; and 82% reported that the provider explained possible side effects of the method chosen, compared to only 70% in 1999. Women’s Health • The majority of respondents (79%) reported having a usual place where they obtain most of their health care. Of those who had a usual place of care, most obtained the care in hospitals (38%) and ambu- latory clinics (i.e. policlinics and women’s consultation clinics) (26%). Only a minority obtained their usual care in primary health care (PHC) facilities (14%). • More than one in every three women (37%) reported visiting a health care facility in the last year. Among these one half (51%) were seen for acute care, 41% for preventive care including family planning ser- vices, and 20% for care of a chronic condition (sum- ming to over 100% due to multiple visits). • One quarter (25%) of respondents indicated they had to delay getting medical care in the last 12 months (preventive, acute, or chronic care). The over- whelming majority of these women (82%) reported that the cost of health care services was the most im- portant deterrent. • Only 22% of women had any health insur- ance at the time of the interview. Given the unequal geographical distribution of the population below the poverty level, insured women in rural areas were much more likely to have government-supported health insurance than urban women and less likely to have private insurance. • The prevalence of routine gynecological visits remains low in Georgia, since only 24% of women with sexual experience had accessed this preventative ser- vice. Since screenings for cervical and breast cancer are generally provided or prescribed during the rou- tine gynecologic visits, the low prevalence of routine gynecologic exams inevitably has an impact on early detection and treatment of the gynecologic cancers. It also has a substantial negative effect on family plan- ning counseling and on dissemination of other health messages. • Overall, 42% of sexually experienced women FINAL REPORT xi had ever performed BSE (breast self exam), which was higher than in 2005 (29%), but still leaves significant room for improvement. In terms of BSE frequency, 17% of sexually experienced women reported doing one every month, 12% every 2–5 months, 12% every 6–12 months or more, and 58% never. • BSE is not adequate on its own; consequently, women were also asked about the utilization of CBE (clinical breast exam) and mammography. Less than one in five (18%) of sexually experienced women had ever had a CBE (done by a health professional to de- tect abnormalities). • Only 10% of women aged 40-44 have ever had a mammography; the three most important rea- sons women gave for not having a mammogram were lack of a recommendation from their health provider, saw no need for it, and never heard of it • The prevalence of cervical cancer screen- ing was also low; only 12% of sexually experienced women reported ever having had a Pap smear test; however, this represents a 3-fold increase from the 4% reported in both 2005 and 1999. • For the first time, the 2010 survey explored the level of awareness and use of the HPV vaccine in Georgia. Only a fifth (21%) of all women aged 15-44 had ever heard of HPV; 18% had heard of the vaccine, and once told about the vaccine’s effectiveness in pre- venting cervical cancer, 29% expressed an interest in receiving it. • Almost all women surveyed (95%) were aware of tuberculosis (TB), and two-thirds (67%) cor- rectly indicated that it is transmitted through the air when coughing. A substantial proportion of women had been exposed to TB either from a family member who has had TB (9%) or from frequent contact with someone else who has had TB (12%). • Only three-quarters (75%) of women were aware that TB can be completely cured. When asked the most appropriate treatment for TB-infected peo- ple, the vast majority (82%) said they should be hos- pitalized, 14% said they should be hospitalized initially and then treated at home, and 2% said they should be treated entirely at home. • Across all age groups, reports of ever, current, and past smoking were low with only 8% of women having ever smoked, 6% being current smokers and 2% past smokers. These figures were higher in urban areas than in rural areas. For example, 9% of urban women reported being current smokers (13% of Tbilisi women), compared to only 2% of rural women. • Although the majority of women surveyed did not smoke, one in two reported high levels of cur- rent (in the past 30 days) secondhand smoke (SHS), both at home and at work. The level of SHS in the home was high, reported by 52% of all women aged 15–44 and by 50% of non-smokers. Among women working indoors, 44% were exposed to SHS, including 40% of non-smokers. • On average, 31% of women have ever drunk alcohol and 17% were current drinkers, but only 2% were current frequent drinkers. Eight percent of women reported binge drinking (5 or more drinks on one occasion) in the three months preceding the sur- vey. Young Adult Behaviors • Nearly a third of young women (aged 15–24 years) in Georgia reported sexual experience (32%); of those, the overwhelming majority (31%) reported sexual initiation after marriage. • One of the most noticeable differences in age at first intercourse is across education levels; over half of women who had secondary education or less had engaged in sexual activity prior to age 22, whereas only 39% of young women with university or techni- cum education had done so. Age at marriage helps explain this. • Among young women who had their first sex- ual intercourse before age of 18, more than half had partners who were 5 or more years older. • Contraceptive use at first sexual intercourse is uncommon in Georgia, regardless of marital status. The primary reasons given for not using a contracep- tive method at first intercourse were wanting to get pregnant (67%) and not thinking about using a meth- od (24%). Domestic Violence • There are new legal regulations and increased efforts to raise awareness on domestic violence. In 2010 women’s reports of violence by an intimate part- ner were quite low: few women reported experience of physical and sexual abuse, either during the last 12 months (2%) or during lifetime (7%). These per- centages remained relatively unchanged since 1999. Moreover, the patterns of formal reports of abuse to the authorities did not change significantly. • Physical abuse by an intimate partner oc- curred in all subgroups regardless of socioeconomic and educational backgrounds, and was the high- est (23%) among previously married women. Higher prevalence of recent physical violence was reported by young women aged 15 to 19 years compared to older women. • Domestic violence has consequences for chil- dren too. On average, 8% of all respondents reported having heard or seen abuse between their parents, and 8% reported that they had experienced parental physical abuse. Witnessing or experiencing domestic abuse as a child increases the likelihood of becoming a victim of intimate partner violence as an adult: among women who had experienced parental abuse, the REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 12xii prevalence of recent psychological abuse was three times as high and prevalence of physical abuse twice as high as among those who had not experienced pa- rental abuse. • Living in households with low gender equity was associated with a higher risk of any type of do- mestic violence. • Among women who had ever experienced physical abuse, about one in three (29%) had not disclosed their experience to anyone. Those who disclosed the abuse had primarily discussed it with a family member or friend; only 5% reported the abuse to the police; 3% sought medical help; and 2% sought legal counsel. • Overall, almost 20% of ever-married women agreed with at least one circumstance in which they consider wife-beating justifiable. This percentage was greater among women who reported lifetime physi- cal or sexual abuse compared to those who had never been abused, suggesting that lack of empowerment may leave women more vulnerable to physical or sex- ual intimate partner violence. FINAL REPORT xiii REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 14xiv PREFACE . iii ACKNOWLEDGEMENTS . v EXECUTIVE SUMMURY . vii CHAPTER 1. INTRODUCTION . 1 1.1 Background . 1 1.2 Objectives . 3 CHAPTER 2. METHODOLOGY . 5 2.1 Sampling Design . 6 2.2 Questiounaire Content . 7 2.3 Data Collection . 7 2.4 Response Rates . 8 2.5 Quality Control Measures . 8 2.6 Sampling Weight . 9 2.7 Comparision with Official Statistics . 9 CHAPTER 3. CHARACTERISTICS OF THE SAMPLE . 11 3.1 Household Characteristics . 12 3.2 Characteristics of the Respondents . 17 3.3 School Entries and Attendance Ratios . 19 CHAPTER 4. FERTILITY AND PREGNANCY EXPERIENCE . 37 4.1 Fertility Levels and Trends . 37 4.2 Fertility Differentials . 40 4.3 Nuptiality . 41 4.4 Age at First Intercourse, Union and Birth . 43 4.5 Recent Sexual Activity . 45 4.6 Planning Status of the Last Pregnancy . 45 4.7 Future Fertility Preferences . 47 4.8 Infertility Problems . 49 CHAPTER 5. INDUCED ABORTION . 61 5.1 Abortion Levels and Trends . 62 5.2 Induced Abortion Differentials. 66 TABLE OF CONTENT FINAL REPORT xv 5.3 Abortion Services . 67 5.4 Abortion Complications . 72 5.5 Reasons for Abortion . 73 CHAPTER 6. MATERNAL AND CHILD HEALTH . 87 6.1 Maternal Mortality Statistics . 87 6.2 Prenatal Care . 88 6.3 Intrapartum Care . 95 6.4 Postpartum Care . 97 6.5 Smoking and Drinking During Pregnancy . 99 6.6 Pregnancy and Postpartum Complications . 100 6.7 Poor Birth Outcomes . 100 6.8 Breastfeeding . 101 6.9 Infant and Child Mortality . 102 CHAPTER 7. CONTRACEPTIVE KNOWLEDGE . 125 7.1 Contraceptive Awareness and Knowledge of Use . 125 7.2 Most Important Source of Information about Contraception . 129 7.3 Knowledge about Contraceptive Effectiveness . 130 CHAPTER 8. CONTRACEPTIVE USE . 139 8.1 Ever Use of Contraceptives . 139 8.2 Current Use of Contraceptives . 141 8.3 Source of Contraception . 146 8.4 Desire to Use a Different Contraceptive Method . 148 8.5 Users of Traditional Methods . 148 8.6 Reasons for not Using Contarception . 150 8.7 Intention to Use Contraceptives Among Non-users . 150 CHAPTER 9. NEED FOR CONTRACEPTIVE SERVICES . 169 9.1 Potential Demand and Unmet Need for Contraception . 170 9.2 Potential Demand for Family Planning by Fertility Preferences . 170 CHAPTER 10. CONTRACEPTIVE COUNSELING . 177 10.1 Client-Provider Communications Regarding Family Planning . 177 10.2 Satisfaction with Counseling Services . 180 10.3 Postabortion and Postpartum Counseling . 181 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 16xvi FINAL REPORT xvii CHAPTER 11. OPINIONS ABOUT CONTRACEPTION . 187 11.1 Opinions on Method Effectiveness . 187 11.2 Opinions on Advantages and Disadvantages of the Bill and the IUD . 189 11.3 Opinions on the Risks of Contarceptive Use . 190 11.4 Desire for More Information on Contraceptive Methods . 191 CHAPTER 12. REPRODUCTIVE HEALTH KNOWLEDGE AND OPINIONS . 205 12.1 Ideal Family Size . 205 12.2 Knowledge of the Menstrual Cycle . 206 12.3 Knowledge of the Contraceptive Effect of Breastfeeding . 207 12.4 Opinions on the Acceptability of Abortion . 207 12.5 Attitudes and Opinions toward Family and Reproductive Roles . 209 CHAPTER 13. HEALTH BEHAVIOR . 219 13.1 Utilization of Health Care Services . 219 13.2 Prevalence of Routine Gynecologic Visits . 221 13.3 Breast Cancer Screening . 221 13.4 Cervical Cancer Screening and HPV Awareness . 223 13.5 Tuberculosis Awareness and Exposure . 225 13.6 Cigarette Smoking . 226 13.7 Alcohol Use . 227 13.8 Prevalence of Selected Health Problems . 227 CHAPTER 14. FAMILY LIFE EDUCATION . 247 14.1 Opinions about Family Life Education at Schools . 247 14.2 Discussions about Sex Education. Topics with Parents . 249 14.3 Family Life Education at Schools . 249 14.4 Sources of Information on Sexual Matters . 250 14.5 Impact on Knowledge about Fertility Issues from Exposure at School or with Parents . 251 CHAPTER 15. YOUNG ADULTS SEXUAL AND CONTRACEPTIVE EXPERIENCE . 259 15.1 Sexual Experience . 259 15.2 Partner at First Intercourse . 260 15.3 Contarceptive Use at First Intercourse, Current Sexual Activity and Contarceptive Use . 261 15.4 Opinions and Attitudes about Condoms and Condom Use . 262 CHAPTER 16. SEXUALLY TRANSMITTED INFECTIONS OTHER THAN HIV/AIDS . 273 16.1 STIs in Georgia and Former Soviet Countries . 273 16.2 Awareness of STIs . 274 16.3 Awareness of Symptoms Associated with STIs . 274 16.4 Self-Perceived Risk of Contracting an STI . 275 16.5 Self-Reported STI Testing . 275 16.6 Self-Reported STI Symptoms . 276 16.7 Primary Sources of Information on STIs . 278 CHAPTER 17. HIV/AIDS . 289 17.1 HIV/AIDS in Georgia . 289 17.2 Awareness and Correct Knowledge of HIV/AIDS . 289 17.3 HIV testing . 291 17.4 Sources of Information on HIV/AIDS . 293 17.5 Knowledge of HIV transmission . 293 17.6 Knowledge of HIV prevention . 294 17.7 Self-perceived of HIV/AIDS . 295 CHAPTER 18. DOMESTIC VIOLENCE . 309 18.1 History of Winessing or Experiencing Parental Physical Abuse . 311 18.2 Prevalence of Intimate Partner Violence . 312 18.3 Seeking Help for Intimate Partner Violence . 312 18.4 Aspects of Intimate Partner Relationships and Gender Norms . 313 ANNEX A: INSTITUTIONAL PARTICIPATION . 322 ANNEX B: FIELD AND DATA ENTRY PERSONNEL . 324 REFERENCES . 325 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 18xviii 1 INTRODUCTION 1.1 Background The status of women’s health in Georgia is strongly influenced by cultural, historical, and socioeconomic factors. The old health system placed emphasis on cu- rative rather than preventive services, relied on spe- cialized care and did not maintain adequate primary health care services. Subsequently, family planning services received little support as well. With the end of the centralized USSR administration and the following economic decline, the costly hospi- tal-based curative system became impossible to main- tain. Most hospitals lacked minimal equipment, drugs, and supplies, and could not afford maintenance costs. In response to the collapse of the publicly-supported hospital-based health system, Georgia’s health sec- tor went through several transformation stages. Since 2007 the Government has initiated bold health care reforms to develop an insurance-based health care fi- nancing system targeted at the poor population, while increasing the share of public resources allocated to public health interventions. The 2011-2015 national healthcare strategy “Access to Quality Healthcare” outlined a new plan for health- care development. The complete replacement of the obsolete hospital infrastructure by modern district healthcare centers that combine primary, pre-hospi- tal, and hospital care services will be fully complete by 2013. Significant improvements in family planning (FP) and reproductive health (RH) service provision have marked the last few years in Georgia. The Govern- ment with the support of international and local non- governmental communities is increasingly supporting staff retraining, education, and infrastructure develop- ment to increase access to quality FP and RH services. Public health interventions and government financed services currently include TB, HIV/AIDS, immunization, mother and child health including universal access to antenatal care, and breast and cervical cancer screen- ing services. However challenges still exist to integrate family planning and other reproductive health servic- es in the health insurance schemes. Family planning activities are currently supported by several donor initiatives, primarily from the United States Agency for International Development (USAID) and the United Nations Population Fund (UNFPA). USAID, UNFPA, and other bilateral and multilateral do- nors have supported the efforts of the Georgian gov- CHAPTER 1 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 2 ernment and local non-governmental organizations to increase access to reproductive health and fam- ily planning services. Since the early 1990s, most of the efforts have focused on designing client-centered family planning and reproductive health policies and programs, training physicians and other medical pro- fessionals, organizing public information campaigns, and developing a nationwide system for delivery of contraceptive supplies. USAID has funded several reproductive health ini- tiatives, including the Healthy Women in Georgia (HWG) project (concluded). The HWG project, im- plemented by the John Snow Research and Training Institute (JSI), primarily focused on evidence-based, women-friendly, and client-focused family planning and reproductive health services. More emphasis was placed on maternity and newborn care by introduc- ing effective perinatal care in 16 maternities. Family planning services were expanded to several hundred service delivery points. The program also supported breast and cervical cancer screening, quality of care in reproductive health, family life education courses, and other initiatives. In 2008-2009, MoLHSA in collabora- tion with CDC and HWG conducted the first mortality study among women of reproductive age (RAMOS) with USAID support. Since then, USAID has funded two additional RH pro- grams, also implemented by JSI: SURVIVE (breast and cervical cancer prevention), conducted in 2009–2010, and SUSTAIN, which is currently in progress. SUSTAIN continues to provide FP training for primary health care and family doctors, pediatricians, and OB/Gyns, and supports the implementation of EPC principles through EPC training for multidisciplinary teams. UNFPA has provided Georgia with reproductive health commodities and supplies since 1993, including sup- plies of modern FP methods, for all regions of Georgia. Building on the results achieved during the previous years, UNFPA’s second Country Program, for 2011- 15, supports implementation of the ICPD Program of Action and the Georgia National Health Strategy 2011-15, and includes large portfolios of RH activi- ties in three main areas: strengthening RH policies, enhancing the legislative environment, and improving quality of services according to internationally recog- nized standards. UNFPA also supports the National RH Council (NRHC), initiated and chaired by the First Lady of Georgia since 2006, and in partnership with MoL- HSA helps to develop and implement clinical practice guidelines for RH, including EmOC, FP, cervical and breast cancer screening, etc. UNFPA also supports the integration of RH services at the PHC level through training for PHC providers on relevant RH services, such as antenatal care, postpar- tum care, FP, and breast and cervical cancer screening, including practical training on Pap-test methodology. MOLHSA and the Reproductive Health Council also col- laborate with UNICEF and the Sheba Medical Centre of Israel, to strengthen the perinatal/neonatal system in the country. In addition, MOLHSA and the Ministry of Justice in collaboration with UNICEF collaborated to introduce a Parent-Baby Book (Personal Record for Child Health and Development) in 2011. The book provides parents of all newborns in the country with essential knowledge of child health and development in the first six years. The partnership of UNFPA/Georgia and Municipality of Tbilisi for reproductive tract cancer prevention and early diagnoses, initiated in 2006, was chosen for a “Pearl of Wisdom” award at the European Parliament Cervical Cancer Prevention Summit in 2009. From 2008 to 2012, in Tbilisi, more than 57,000 women benefited from breast cancer screening (clinical ex- amination or mammography) and more than 59,000 women benefited from cervical cancer screening ser- vices. The program was subsequently expanded by the MOLHSA/NCDC to all regions of Georgia. UNFPA has also supported youth reproductive health initiatives, including the introduction of youth-friendly reproductive health services, youth awareness rising on SRH&R through peer education. Through the government’s efforts and the support provided by international donor organizations, Geor- gia has increased women’s access to modern contra- ceptives and other reproductive health services. How- ever, many challenges remain, particularly to further improve access and quality of services. To help poli- cymakers and program managers assess and respond to current needs, nationwide surveys on reproductive health were conducted in Georgia in 1999, 2005 and 2010. Two major international agencies have primarily supported these surveys: USAID, which funded tech- nical assistance from the US Centers for Disease Con- trol and Prevention’s Division of Reproductive Health (CDC/DRH), and UNFPA, which covered costs related to field work, translation, and dissemination seminars. Technical assistance and funding for the 2010 survey was also contributed by the United Nations Children Fund (UNICEF). For all three surveys, CDC/DRH pro- vided technical assistance to the National Centers for Disease Control and Public Health (NCDC) the main implementing agency. The 1999 Georgia Reproductive Health Survey (GER- HS) was the first national representative household survey ever conducted in Georgia and it document- FINAL REPORT 3 ed low levels of contraceptive use and high levels of abortion. The second round of GERHS was carried out during the first part of 2005. Similarly, the 2010 GER- HS continues to document RH efforts, as well as the trends in the main RH indicators. The 2010 question- naire incorporated certain indicators from UNICEF’s Multiple Indicator Cluster Survey (MICS), specifically related to children’s education, water, sanitation, and hygiene issues. The 1999 survey included a supple- mental sample of internally displaced women living in nonresidential housing, which was not replicated in the later rounds. All three surveys used nationally representative sam- ples of women aged 15–44 and were similar in scope, design and content, with multistage probability sam- ples. The selection of primary sampling units in 2005 and 2010 was based on the 2002 Census and allowed for independent regional estimates for the most im- portant reproductive health indicators. However the sampling design in 1999, based on the sampling frame of MICS 1999, did not permit independent estimates for all regions. The availability of high-quality RHS data has revealed levels of contraceptive use and induced abortion in Georgia with more accuracy than was previously pos- sible. Survey estimates of contraceptive prevalence are more accurate than estimates based on service statistics, which count only women attending facilities that provide family planning services. Survey-based estimates of the number of abortions in Georgia are also higher than official values; however in recent years the official estimates are coming closer to the survey figures, indicating improved reporting. Two other surveys have augmented the information available for this report. One is the MICS (Multiple In- dicator Cluster Survey) of 2010-11, used to add infor- mation to Chapter 3. The other is the special survey on domestic violence of 2009 (Chitashvili et al., 2010), used especially in chapter 18. 1.2 Objectives Periodic household-based probability surveys are the best and most timely way to collect data on a wide assortment of health topics that are essential to de- termining the health needs of Georgian families and the types of services they should receive. Set within the context of overall social and economic develop- ment in Georgia, the aim of the 2010 survey was to obtain national and regional estimates of basic demo- graphic and reproductive health indicators, in order to set targets for improvements, allocate resources, and monitor performance of family planning and maternal and child health programs. The survey interviewed a sample of 6,292 women aged 15–44 years between October 2010 and February 2011. It was similar in de- sign and content to the 1999 and 2005 surveys as not- ed above, as well as with surveys conducted in other Eastern European and Central Asian countries. The GERHS10 was specifically designed to meet the following objectives: • to assess the current situation in Georgia con- cerning fertility, abortion, contraception and various other reproductive health issues; • to enable policy makers, program managers, and researchers to evaluate and improve existing pro- grams and to develop new strategies; • to document the socio-economic character- istics of households in Georgia and their patterns of access to and utilization of health care services; • to measure changes in fertility and contra- ceptive prevalence rates and study factors that affect these changes, such as geographic and socio-demo- graphic factors, breast-feeding patterns, use of in- duced abortion, and availability of family planning; • to provide data needed to estimate global de- velopment indicators related to education, maternal and child survival, gender equality, and reduction of HIV and other disease transmission; • to obtain data on knowledge, attitudes, and behavior of young adults 15–24 years of age and as- sess their exposure to sex education and health pro- motion programs; • to identify topics of special interest regarding reproductive health among high risk groups. By making available appropriate country- and region- specific data on reproductive health and related health services and enhancing the ability of national organizations to collect, analyze, and disseminate such information, the survey has fostered collabora- tion between the Georgian government, international donors, and other partners. Survey data will be used to monitor RH and maternal and child health programs within the context of Georgian health sector reforms and poverty reduction strategies. The survey will also help to identify linkages among health needs, health services, and health sector reforms. International bi- lateral and multilateral donors (e.g., USAID, UN agen- cies, World Bank, and EU) and various government partners, particularly MoLHSA, the Ministry of Eco- nomic Development, and Ministry of Finance, can use these data for developing new health strategies and health sector reforms under ‘Strategic “10-Point Plan” of the Government of Georgia for Modernization and Employment’ and ‘National health care strategy - Ac- cess to Quality Health Care’, as well as for monitoring and evaluating progress toward achieving the UN Mil- lennium Development Goals. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 4 5 METHODOLOGY Worldwide, population-based surveys are widely used to complement the routine health information sys- tems. They have the advantage of providing informa- tion on a large number of health issues and can track progress of health programs and evaluate their im- pact for the population as a whole or for specific risk groups. The Reproductive Health Surveys (RHS) were developed by Centers for Disease Control and Preven- tion (CDC) in response to the need to collect detailed reproductive, maternal, and child health indicators in international settings (Morris, 2000). These surveys draw upon the CDC expertise in family planning and women’s health survey methodologies in the United States, combined with its international experience. Beginning in the mid-1990s, several RHS surveys were conducted in Eastern Europe with CDC technical as- sistance, including three surveys in Georgia. A major purpose of the RHS is to produce national and sub-national estimates of factors related to pregnancy and fertility, such as sexual activity and contraceptive use, use of abortion and other medical services, and maternal and infant health. The first RHS was conduct- ed in Georgia in 1999; a new cycle was implemented in March-July 2005, followed by the third Georgian RHS (GERHS10), implemented in 2010. As was the case with the first two rounds, the Georgian Minis- try of Labor, Health and Social Affairs (MoLHSA) con- ducted the survey in collaboration with the Georgian National Center for Disease Control. CDC provided technical assistance with the survey design, sampling, questionnaire development, training, data process- ing, and analysis to all rounds of the RHS in Georgia through funding from the United States Agency for International Development (USAID). All local costs of GERHS10, including the dissemination activities, were supported by the United Nations Population Fund (UNFPA) and the United Nations Children’s Fund (UNICEF). All RHS in Georgia employed nationally representa- tive, probability samples and collected information on a wide range of health related topics from women of reproductive age. A major function of successive cycles of the survey is to produce comparable time trend data. Thus, the 2005 survey was modeled after the 1999 RHS and the 2010 drew from the experience of the previous rounds and added some new content. The content of all surveys was reviewed by Georgian national experts, government representatives, and re- searchers from inside and outside governmental or- ganizations, as well as donor agencies. The panel of experts who reviewed the questionnaire and the main findings of GERHS10 is attached. CHAPTER 2 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 6 Each survey collected information from a representa- tive sample of Georgian women aged 15–44 years, so the data can be used to estimate percentages, aver- ages, and other measures for the entire population of women of reproductive age residing in Georgian households at the time when the survey was imple- mented. 2.1 Sampling Design Similar to the 1999 and 2005 RHS surveys, the GER- HS10 is based on a large representative probability sample (13,363 households) and consists of face-to- face interviews with women of reproductive age at their homes. The population from which the respond- ents were selected included all females between the ages of 15 and 44 years, regardless of marital status, who were living in households in Georgia during the survey period (excluding the separatist regions of Ab- khazia and South Ossetia). This sample was selected in such a manner as to allow separate urban and rural, as well as regional-level es- timates for key population and health indicators, such as fertility, abortion, contraceptive prevalence, mater- nal and child health, and infant mortality for children under five. The number of households included in the sample was set to yield approximately 6,000 interviews with women aged 15-44. As in the 2005 RHS, the survey employed a stratified multistage sampling design that used the 2002 Georgia census as the sampling frame (State Department for Statistics, 2003). To better mon- itor the health issues at a sub-national level and assist key stakeholders in assessing decentralization efforts, the sample was designed to produce estimates for 11 regions of the country. Census sectors were grouped into 11 strata, corresponding to Georgia’s administra- tive regions; three small regions, Racha-Lechkhumi, Kvemo Svaneti, and Zemo Svaneti were included in one stratum, identified as the Racha-Svaneti stratum. Figure 2.1 compares the distribution of households in the 2002 census with the distribution of households that resulted in the sample. The first stage involved selection of a sample of pri- mary sampling units (PSUs), which were the same census sectors selected in the 2005 survey. The first stage selection was done with probability of selection proportional to the number of households in each of the 11 regional sectors. A systematic sampling process with a random starting point in each stratum was ap- plied. During the first stage, 310 census sectors were selected as primary sampling units (PSUs), as shown in Table 2.1. Therefore the overall sample consisted of 310 PSUs, and the target number of completed interviews was an average of 20 completed interviews per PSU. The minimum acceptable number of interviews per stra- tum was set at 400, so that the minimum number of PSUs per stratum was set at 20. With these criteria, 20 PSUs were allocated to each stratum, which accounted for 220 of the available PSUs. Another 80 PSUs were distributed in the largest regions in order to obtain a distribution of PSUs approximately proportional to the distribution of households in the 2002 census. An additional 10 PSUs were added to the smallest stra- tum, Racha-Svaneti, to compensate for the consider- able sparseness of women of reproductive age in this stratum. 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 305,896 124,031 87,527 201,213 Sample (RHS) Census (2002) 3000 2500 2000 1500 1000 500 0 1056 2734 841 1053 51,381 643 39,743 115,982 20,395 109,632 1684 34,834 83,391 842 1005 1057 845 1603 320,000 280,000 240,000 200,000 160,000 120,000 80,000 40,000 0 Households in Sample Households in Census Number of Households in the 11 Strata of the GERHS10 Sample and the 2002 Census Figure 2.1 FINAL REPORT 7 Table 2.1 also compares the distribution of households in the sample with the distribution of households in the 2002 Census by the 11 strata. The sampling frac- tion ranges from 1 in 13 households in the Racha- Svaneti stratum (the least populated stratum) to 1 in 136 in Adjara. As shown in Table 2.1, if the ratio of households in the census to households in the sample is above 100.0, the region has been under-sampled, whereas if the ratio is less than 100.0, the region has been over-sampled. In the second stage of sampling, clusters of house- holds were randomly selected from each census sec- tor chosen in the first stage. A listing of each of the selected PSUs had been carried out in preparation for the 2005 survey. The 2010 survey selected house- holds from the updated household listing in each PSU. Determination of cluster size was based on the num- ber of households required to obtain an average of 20 completed interviews per cluster. The total number of households in each cluster took into account esti- mates of unoccupied households, the average num- ber of women aged 15–44 per household, the rule of interviewing only one respondent per household, and an estimated response rate of 98%. In the case of households with more than one woman between the ages of 15 and 44, one woman was selected at random to be interviewed. 2.2. Questionnaire Content Similar to the 1999 and 2005 RHS, GERHS10 used two questionnaires to collect information from the house- holds and from eligible respondents: the household questionnaire and the women’s questionnaire. Both questionnaires produced in both the Georgian and Russian languages. The household questionnaire included details on the household’s composition, questions about the edu- cation attainment of the household members and school readiness and attendance among children and youth, socio-economic characteristics of the house- hold, and questions about the availability and type of social assistance received by household members. These questions were adapted for Georgia’s needs us- ing the RHS model household questionnaire and the fourth round of the Multiple Indicator Cluster Surveys (MICS) developed by UNICEF. As in the previous surveys, the women’s question- naire for GERHS10 was designed to collect informa- tion on the following: • Demographic characteristics • Fertility and child mortality • Family planning and reproductive preferences • Use of reproductive and child health care ser- vices • Range and quality of maternity care services • Use of preventive and curative health care ser- vices • Reproductive health care expenditures • Perceptions of health service quality • Risky health behaviors (smoking and alcohol use) • Young adult health education and behaviors • Intimate partner violence • HIV/AIDS and other STDs Additionally, a series of questions was asked to as- sess the awareness and occurrence of tuberculosis and other chronic illnesses, the use of breast cancer screening, and awareness and use of the HPV vaccine. Finally, women were asked a number of questions aimed at assessing their access to preventive and cu- rative health services, their health insurance status, and affordability and costs of health services. Because a wealth of similar reproductive health sur- vey data from other countries in Eastern Europe are available, cross-country comparisons can be made, and successful regional approaches could be adapted to the country-specific context. 2.3 Data Collection The interviews were performed by 40 female in- terviewers trained in interview techniques, survey procedures, and questionnaire content. Interviewer training took place at the NCDC headquarters just be- fore data collection began. Interviewer training was conducted mostly in Georgian by a team of trainers. The training team consisted of three consultants from CDC and staff from NCDC. At the end of the training period, eight teams were selected, each consisting of five female interviewers, one supervisor, and two drivers. All interviewers were bilingual (Georgian and Russian). Fieldwork was managed by staff of NCDC, with technical assistance from CDC, and lasted from October 2010 through February 2011. Each team was assigned several primary sampling units and traveled by car throughout the country on planned itineraries. The majority of interviews were conducted in Geor- gian while approximately 20% were conducted in Rus- sian. Azeri-speaking health professionals facilitated interviews with monolingual Azeri respondents. Com- pleted questionnaires were first reviewed in the field by team supervisors and then taken by the fieldwork coordinators to the NCDC fordata processing. The field unit for GERHS10 consisted of two coordi- nators who divided the fieldwork assignments among the eight teams of interviewers and supervisors. The field work coordinators and supervisors prepared in- terviewer assignments and were responsible for mon- itoring the progress of each interviewer, performing REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 8 field observations, conducting in-person verifications of the interviewers’ work, and conducting refusal con- version efforts. Field supervisors were also responsi- ble for analyzing each interviewer’s weekly produc- tion and quality of work, reviewing errors, and serving as the point of contact for the data entry supervisors. 2.4 Response Rates Of the 13,363 households selected in the household sample, 6,356 included at least one eligible woman (aged 15–44 years). Of these identified respondents, 6,292 women were successfully interviewed, yield- ing a response rate of 99%. Virtually all respondents who were selected to participate and who could be reached agreed to be interviewed and were very co- operative. The refusal rates for the household ques- tionnaire and the women’s questionnaire were very low (0.2%). Response rates did not vary significantly by geographical location (Table 2.2). 2.5 Quality Control Measures A number of measures were taken to ensure that the data were of the highest possible quality. First, the questionnaire, already refined during the previ- ous RHS rounds in Georgia, was revised carefully and reviewed by a panel of Georgian experts. As a result, the content of the questionnaire was expanded sub- stantially and made more relevant for programmatic needs. The questionnaire was tested extensively, both before and during the pretest and prior to beginning the field work. Testing included practice field inter- views and simulated interviews conducted by both CDC and NCDC staff. The questionnaire was translated into Georgian and Russian and back-translated into English. The training team selected 40 interviewers and 8 su- pervisors after one week classroom training and an- other week in the field. The training was very com- petitive and allowed for selection of the most highly qualified staff from an original pool of 75 trainees. Supervisors were trained to review and edit the ques- tionnaires immediately after each interview; thus, if they noticed errors or omissions the interviewers or the respondents had made, the interviewers could make immediate corrections during short follow-up visits. These edits reduced the item nonresponse rate for most questions to less than 2%. Supervisors and field work coordinators spot-checked the quality of each interviewer’s work often and carefully. This pro- cess of verifying fieldwork was a critical component of the overall quality control system. The inclusion of life histories (marital history and pregnancy history) and the five-year month-by-month calendar of pregnancy, contraceptive use, and union status helped respondents accurately recall the dates of one event in relation to the dates of others they had already recorded. Consistency checks between life events were programmed into the data entry soft- ware, so that data entry supervisors would notice er- rors or inconsistencies and could send problematic interviews back to the field for follow-up visits. The CDC team followed the progress of fieldwork by receiving approximately every two weeks a standard set of quality control tables generated from the most recently collected data. In addition, the team spent four weeks in the field and accompanied all teams for visits in several PSUs. Along with the NCDC team members, the CDC staff observed fieldwork, reviewed progress, and checked the quality of fieldwork. 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Percentage Age Distribution of Women Aged 15–44, 2010 RHS and 2002 Census Figure 2.2 Age Group 15-19 20-24 25-29 30-34 35-39 40-44 25 20 15 10 5 0 Sample (2010) Census (2002) FINAL REPORT 9 2.6 Sampling Weights The purpose of the RHS is to produce statistical esti- mates that are nationally representative. National es- timates are produced by devising a “sampling weight” for each respondent that adjusts for her probability of selection in the sample. The weights for the RHS were calculated as follows: First, the weight was adjusted to reflect the selection of only one eligible woman from each household containing women of reproductive age. In cases where households included more than one eligible female respondent, the woman who was selected for interview received an additional weight. Second, the weight was adjusted to reflect that women residing in the regions with sparser populations were selected at higher rates (i.e., were over-sampled) rela- tive to those residing in regions with high population density, who were under-sampled. Because the over- all response rate (99%) was so high, no weighting was needed to adjust for the survey staff’s inability to lo- cate some eligible women or for nonresponse among those who were located. After the weighted survey population distribution was broken down by five-year age groups and by residence and was compared with the Census estimates, poststratification weights were not deemed to be necessary (see Section 2.7). Except for Table 2.2, all tables in this report present weighted results, but the unweighted number of cas- es, used for variance estimation, is shown in each ta- ble. Generally, tables where percent distributions are shown should add up to 100%, but due to rounding they may add up to either 99.9% or 100.1%. 2.7 Comparison with Official Statistics The weighted percentage distribution of women se- lected in the 2010 survey sample by 5-year age groups differs only slightly from the 2009 mid-year official estimates, based on the official census projections (Table 2.3). For the overall distribution by age, the dif- ferences were not statistically significant after confi- dence intervals are taken into account. Unfortunately, the urban/rural distribution of the sample cannot be compared with current official estimates because the official statistics do not project population figures separately for the urban and rural areas. Compared to 2002, both the total and the urban/rural distribution of the sample include fewer women aged 35–39 and 40–44 (Figure 2.2). However, the age composition had changed significantly since 2002 so comparisons need to be made with projected population figures. The of- ficial age projections for 2009 for the percentages of women in these age groups are similar to the figures documented by GERHS10 and there was no great vari- ation in age distribution among these women when stratified by urban or rural residence. These findings suggest that the sample distribution of women aged 35–39 and 39–44 by residence would be close to the official projections, if such projections were available. Table 2.1 Number of Households (HH) in the GERHS10 Sample and the 2002 Census and in the Sample, by Region, Reproductive Health Survey: Georgia, 2010 Strata (Regions) No. of HH in Census No. of PSUs in Sample No. of HH Sampled Ratio of HH-Census to the HH in Sample No. of Completed Women's Interviews Kakheti 109,632 25 1056 103.8 498 Tbilisi 305,896 65 2734 111.9 1,426 Shida Kartli 83,391 20 841 99.2 392 Kvemo Kartli 124,031 25 1053 117.8 546 Samtskhe-Javakheti 51,381 20 842 61.0 481 Adjara 87,527 20 643 136.1 419 Guria 39,743 20 1005 39.5 401 Samegrelo 115,982 25 1057 109.7 477 Imereti 201,213 40 1684 119.5 805 Mtskheta-Mtianeti 34,484 20 845 40.8 393 Racha-Svaneti† 20,395 30 1603 12.7 454 Total 1,173,675 310 13,363 87.8 6,292 *Source: SDS, 2002 Census Population HH = households; PSU = primary sampling unit the Ratio of the Number of Households in the Census to the Number of Households † Includes the regions of Racha-Lekhumi, Kvemo Svaneti, and Zemo Svaneti as one stratum. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 10 Ta bl e 2. 2 R es ul ts o f H ou se ho ld V is its a nd In te rv ie w S ta tu s of E lig ib le W om en , b y R es id en ce R ep ro du ct iv e H ea lth S ur ve y: G eo rg ia 2 01 0 Tb ili si O th er U rb an R ur al K ak he ti Tb ili si Sh id a K ar tli K ve m o K ar tli Sa m ts kh e- Ja va kh et i A dj ar a G ur ia Sa m eg re lo Im er et i M ts kh et a- M tia ne ti R ac ha - Sv an et i Id en tif ie d el ig ib le w om an 47 .6 52 .7 49 .5 44 .9 47 .4 52 .7 47 .0 52 .0 57 .5 65 .6 40 .8 45 .5 48 .1 47 .7 28 .7 N o el ig ib le w om en 49 .0 43 .7 48 .0 51 .4 49 .5 43 .7 50 .2 44 .8 40 .1 30 .9 59 .0 53 .8 48 .9 49 .5 62 .2 R es id en t(s ) n ot a t h om e 0. 1 0. 5 0. 0 0. 1 0. 2 0. 5 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 2 0. 0 H ou se ho ld re fu sa l 0. 2 0. 9 0. 1 0. 1 0. 0 0. 9 0. 0 0. 4 0. 2 0. 0 0. 0 0. 0 0. 0 0. 1 0. 1 U no cc up ie d ho us e 3. 0 1. 9 2. 4 3. 6 2. 8 1. 9 2. 9 2. 8 2. 0 3. 4 0. 2 0. 7 3. 0 2. 4 9. 0 O th er 0. 1 0. 3 0. 1 0. 0 0. 0 0. 3 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N o. o f H ou se ho ld s Vi si te d 13 ,3 63 2, 73 4 3, 15 2 7, 47 7 1, 05 6 2, 73 4 84 1 1, 05 3 84 2 64 3 1, 00 5 1, 05 7 1, 68 4 84 5 1, 60 3 El ig ib le W om en C om pl et ed in te rv ie w s 99 .0 98 .9 99 .4 98 .9 99 .4 98 .9 99 .2 99 .6 99 .4 99 .3 97 .8 99 .2 99 .4 97 .5 98 .7 S el ec te d re sp on de nt s no t a t h om e 0. 1 0. 3 0. 1 0. 1 0. 0 0. 3 0. 0 0. 0 0. 0 0. 0 0. 7 0. 0 0. 0 0. 0 0. 0 S el ec te d re sp on de nt re fu se d 0. 2 0. 3 0. 1 0. 1 0. 6 0. 3 0. 0 0. 0 0. 0 0. 0 0. 2 0. 2 0. 0 0. 2 0. 0 S el ec te d re sp on de nt is n ot c om pe te nt 0. 7 0. 4 0. 5 0. 9 0. 0 0. 4 0. 8 0. 4 0. 6 0. 7 1. 2 0. 6 0. 6 2. 2 1. 3 In co m pl et e In te rv ie w 0. 0 0. 1 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N o. o f E lig ib le W om en Id en tif ie d 6, 35 6 1, 44 2 1, 55 9 3, 35 5 50 1 1, 44 2 39 5 54 8 48 4 42 2 41 0 48 1 81 0 40 3 46 0 R eg io n R es id en ce To ta l H ou se ho ld s Vi si ts N o. o f C om pl et ed in te rv ie w s 6, 29 2 1, 42 6 1, 54 9 3, 31 7 49 8 1, 42 6 39 2 54 6 48 1 41 9 40 1 47 7 80 5 39 3 45 4 Ta bl e 2. 3 W om en w ith C om pl et e In te rv ie w s C om pa re d w ith O ffi ci al E st im at es b y R es id en ce , by A ge G ro up . R ep ro du ct iv e H ea lth S ur ve y: G eo rg ia 2 01 0 20 09 O ffi cia l E st im at es (m id -y ea r)* To ta l To ta l Ur ba n Ru ra l 15 –1 9 17 .9 (1 .3) 17 .4 (1 .3) 18 .6 (1 .3) 17 .2 17 .6 16 .7 18 .8 20 –2 4 18 .9 (1 .4) 19 .7 (1 .4) 18 .0 (1 .3) 18 .1 16 .4 16 .2 16 .7 25 –2 9 16 .6 (1 .3) 16 .3 (1 .3) 17 .0 (1 .3) 17 .0 15 .8 15 .9 15 .8 30 –3 4 16 .3 (1 .3) 16 .7 (1 .3) 15 .9 (1 .3) 16 .1 15 .5 15 .6 15 .3 35 –3 9 15 .8 (1 .3) 15 .6 (1 .3) 16 .1 (1 .3) 15 .8 17 .0 17 .4 16 .6 40 –4 4 14 .4 (1 .4) 14 .3 (1 .3) 14 .5 (1 .4) 15 .8 17 .7 18 .3 16 .8 To ta l 10 00 10 00 10 00 10 00 10 00 10 00 10 00 Ag e G ro up 20 02 O ffi cia l E st im at es † To ta l U rb an Ru ra l GE RH S1 0 ( ±9 5% C on fid en ce In te rv al) To ta l 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 * S DS , 2 01 1: Mi d- ye ar po pu lat ion ac co rd ing to ag e a nd se x g ro up s, Ge or gia , 2 00 8 – 20 09 †  SD S, 20 03 . P op ula tio n o f G eo rg ia in 20 02 . 11 CHAPTER 3 CHARACTERISTICS OF THE SAMPLE The survey documents a wide array of key reproductive health outcomes and their determinants for women of reproductive age. To better understand these out- comes, Chapter 3 presents the main characteristics of the survey respondents that will be used throughout the report. Geographic key variables are area of resi- dence, meaning either urban and rural or else Tbilisi, other urban area, and rural area; as well as region of residence (11 regions). Key demographic variables are the age at the time of the interview, which is grouped by five years (or by ten years in some tables in other chapters), and current marital/union relationship sta- tus. The latter consists of 4 types: two formal union relationships (legal marriage and common-law union), one previous union relationship (widowed, divorced and separated women), and women who have never been married. Socioeconomic variables include education and the wealth status of the household . Education is catego- rized into secondary incomplete or less (roughly cor- responding to 0–10 years of education), secondary complete (11–12 years of education), postsecondary technical education (high vocational education), and postsecondary academic education. The wealth status is based on household assets, including durable goods (refrigerator, television, car, computer, etc.) and dwell- ing characteristics (type of source for drinking water, toilet facilities, fuel used for cooking and heating, main roof material, and the household’s crowdedness). To construct the index, each household asset was as- signed a weight or a factor score generated through principal component analysis. The resulting asset scores were standardized to have a standard normal distribution with a mean of zero and a standard de- viation of one (Gwatkin et al., 2000). Each household was assigned a standardized score reflecting its exist- ing set of assets and possessions; overall scores were generated by summing the standardized asset-specific scores. Next, the sample of households was divided into five equal-sized groups or quintiles based on a weighted frequency distribution of households by the resulting asset score. The households with the lowest 20% of the total asset scores are classified as quintile 1, the lowest wealth quintile, and the next 20% are classified as quintile 2 or the second wealth quintile, etc. Each respondent was ranked according to the wealth quintile of the household in which she resided. Thus, the wealth index measures the standard of liv- ing of a household relative to other households, in- dicating that respondents living in households with a higher wealth quintile have a better socioeconomic REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 12 status (SES) than those with a lower wealth quin- tile. Table 3.1.1 shows the distribution of the Geor- gian population by wealth quintiles, according to urban-rural residence and region. The distribution indicates the degree to which wealth is distributed in geographic areas. Almost three in four (74%) urban households were classified in the two highest wealth quintiles while only 3% of rural households were in those wealth groups. Looking at regional variation, Tbilisi has the largest proportion of households in the two highest wealth quintiles (91%). In Figure 3.1.1 Racha-Svaneti, Guria, and Samegrelo have the largest proportions of households in the two lowest wealth quintiles (85%, 75%, and 70%, respectively). It is also worth mentioning that previous RHS sur- veys in Georgia did not use the wealth index to char- acterize the SES of the households. Previous surveys used a socioeconomic index based on equal values assigned for possession of household amenities and goods. The resulting scores ranged from 0–9 or 0–10, where 0 represented the lower end (i.e. no score- related amenities or goods in the household) and 9 or 10 represented the higher end (all items present in the household). The score was further divided into terciles to create three levels of the SES of the house- hold. To facilitate comparisons of reproductive health indicators by the SES of the respondents interviewed in the 2010 survey with the results collected in pre- vious surveys, the wealth index created in GERHS10 is also used to create a distribution of households by terciles. The wealth terciles are based on the principal component analysis and classify the households in the sample as being in the lowest 33% of the total asset score, the middle 33%, and the highest 33%. Thus, the trend comparison of indicators by socioeconomic sta- tus should be interpreted with caution, since a slightly different methodology for assessing the SES was em- ployed in the analyses of the 2010 survey. 3.1 Household Characteristics Socio-economic well-being is an important determi- nant of reproductive health status. In order to assess the socio-economic conditions of respondents GER- HS10 collected information on the availability of basic services (such as electricity supply, source of drinking water, type of toilet facilities, energy used for cooking, type of heating system, and roof material) and various goods and amenities (e.g. T.V., telephone, refrigerator, working automobile, satellite dish, computer, VCR/ DVD, etc.) in respondents’ households. The source of drinking water for 76% of households is piped water either into the dwelling, compound, yard, or plot (Table 3.1.2). About 15% of households obtain their drinking water from wells and only for 3% of re- spondents the source of water is spring. Piped water is more common in urban areas (96%) than in rural areas (55%). The availability of piped water increases according to wealth index from 45% in lowest wealth quartile to almost 100% in highest wealth quartile (Ta- ble 3.1.3). Piped water is available in more than 80% of households in the Tbilisi, Adjara and Racha-Svaneti regions (Figure 3.1.2). Piped water is also the main source of drinking water in most other regions except Guria and Samegrelo regions, where most households obtain water from wells. Public taps are the second most important source of drinking water in Kakheti and Kvemo Kartli regions (Table 3.1.2). Overall 93 per- cent of households - 98 per cent of urban and 88 per cent of rural households in Georgia use an improved source of drinking water (water from unprotected wells or unprotected springs being considered as un- 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 100 80 60 40 20 0 66 1 35 54 85 Households in Sample Percentage of Households in the Lowest Two Wealth Quintiles by Region Figure 3.1.1 59 44 50 75 70 43 FINAL REPORT 13 safe). The lowest percentage for improved sources of water is in Samegrelo (69%). (Table 3.1.4). Note: Tables 3.1.4 through 3.1.7 are tabulated us- ing data from the household questionnaires, which include MICS indicators, as do Tables 3.3.1 through 3.3.6. The MICS Indicator Number for each topic ap- pears below each table. (MICS: Multiple Indicator Cluster Survey, developed by UNICEF.) Table 3.1.5 shows that for 76% of households the drinking water source is on the premises. For 20% of households, it takes less than 30 minutes to get to the water source and bring water, while 4% of households spend 30 minutes or more. In 2010 almost all of the households were supplied with electricity for 24-hours per day and there were only slight differences among the regions (Table 3.1.2). There was a dramatic increase in the availabil- ity of uninterrupted electrical power supply between 2005 and 2010 surveys, from 37% to 96% in 2010. As shown in Table 3.1.2, 48% of households have flush toilets, while 50% have pit latrines. The presence of flush toilets at households differs dramatically be- tween urban (84%) and rural (9%) regions. The high- est prevalence of flush toilets was reported in Tbilisi (96%) and the lowest in Kakheti and Racha-Svaneti regions (8%) (Figure 3.1.3). In Table 3.1.6 the pit latrine is the main toilet facility at households in most of the regions except Tbilisi and Adjara. Overall, 84 percent of households use some type of improved sanitation facility (sum of 7 types in Table 3.1.6). By residence this is 96% of urban house- 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) <45 45-54 55-69 70-79 80+ * Abkhazia: Autonomous region not under goverment control Percentage of Households with Piped Water, by Region Figure 3.1.2 % Households with Water Faucet <45 45-54 55-69 70-79 80+ * 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) <45 45-54 55-69 70-79 80+ * Abkhazia: Autonomous region not under goverment control Percentage of Households with Flush Toilet, by Region Figure 3.1.3 % Households with Flush Toilet <20 20-29 30-44 45-54 55+ * REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 14 holds and 71% of rural households. Residents of Samtskhe-Javakheti are less likely than others to use improved sanitation facilities (53%). In rural areas the population is mostly using pit latrines with or without slabs (59% and 24% respectively, and pit latrines with- out slab are considered as unimproved), while in ur- ban areas the most common facilities are flush toilets with connection to a sewerage system (82%). Table 3.1.7 (last column) shows that 79% of the whole population use both improved water and sanitation facilities. A sharp gradient exists across the wealth quintiles, from 56% to 99% for this item. Table 3.1.2, discussed above, indicates that the main source of energy used for cooking in households is natural gas (45%) followed by coal or wood (40%). Electricity is used only in about 4% of households for cooking. Natural gas is the main source of energy for cooking in urban households (74%), while most of the rural households (70%) use coal or wood for cooking. The use of natural gas is highest in Tbilisi (90%) and the lowest in Racha-Svaneti region (2%). Nearly two thirds of households are heated with stoves (66%), followed by individual room heating (29%) with different kinds of space heaters. Central heating is used in only 1.4% of all households, report- ed mostly in Tbilisi. In 2% of households there was no heating available, more common in urban than in ru- ral households. Corrugated iron is the most common material used for roofing (36%), followed by sheet metal (33%) and tile or concrete (26%). Corrugated iron is mainly used in rural regions, while tile or concrete is more common in urban areas. The highest prevalence of households roofed with corrugated iron is in the Guria region (70%), while roofing with tile or concrete predomi- nates in Tbilisi (62%). In summary, urban households are more likely to have piped water, a flush toilet, central heating, and natural gas for cooking. There is no difference in 24- hour electric power supply between urban and rural residence, as it is available for almost all households in both urban and rural places (Figure 3.1.4). The only dwelling characteristic that is more favorable for rural households is the number of rooms per person. Rural dwellings have more rooms per person and are less crowded than urban dwellings. As shown in Table 3.1.8, television is the most com- mon amenity/good found in 97% of Georgian house- holds, with very little difference between urban and rural households. The availability of all other house- hold amenities and goods is higher in urban than in rural places (Figure 3.1.5). Refrigerators and cellular telephones (one at least) are present in more than two thirds of all households (79% and 75% respective- ly). Land-line telephones were reported by more than half of respondents (56%) It should be noted that the urban/rural gap is very large for having a land-line tel- ephone (73% vs. 38%), but it narrows significantly for ownership of cellular phones. While the percentage of urban households with cell telephones is 82%, a substantial proportion of rural households (67%) also have them. The proportion of households with at least one cell telephone ranges from a low 57% in Racha- Svaneti to a high 86% in Tbilisi (Figure 3.1.6). Overall, 25% of households have a functioning auto- mobile, and the ownership rates are highest in the Tbilisi and Samtskhe-Javakheti regions (31%) and the 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Availability of Basic Services in the Household by Residence Figure 3.1.4 Electricity (24 Hours) 100 80 60 40 20 0 Piped Water Flush Toilet Gas or Electric Cooking Central Heating Percentage Urban Rural FINAL REPORT 15 lowest in Racha-Svaneti (13%). Computers and inter- net are present in about 20% of all households, but this varies greatly by residence. Computers exist in 35% of urban but only 6% of rural households. Simi- larly, 34% of urban households and only 4% of rural households have internet supply (Table 3.1.3). Overall, one in five households has a satellite dish, but in this case it is more common in rural (29%) than in urban (14%) areas. Having a VCR/DVD was reported by 19% of all respondents, more in urban (26%) than in rural (11%) households. Air conditioners exist in only 4% of all households, mainly in urban areas. A vacation home (villa) is owned by 7% of respondents, with a great difference between urban and rural resi- dents (12% and 1.2% respectively). The availability of all household amenities and goods is generally higher in urban than in rural areas, except for TV sets, which are found in virtually all urban and rural households (Figure 3.1.5). Figure 3.1.7 shows changes over 11 years in selected basic services in the households. While the availabil- ity of flush toilets has remained basically unchanged, the availability of electricity 24 hours per day has increased more than 10 times, from 9% in 1999 to 96% in 2010. More households now have land-line telephone service (56% vs. 36%) and 10 times more households have central heating. Changes in the avail- ability of household goods are shown in Figure 3.1.8. The only substantial increase has been in ownership of cell telephones, from less than 10% in 1999 to al- most 75% in 2010. In contrast, during these 11 years, the percentage of households with a villa declined sig- 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Availability of Household Goods by Residence Figure 3.1.5 TV 100 80 60 40 20 0 Re fri ge ra to r Ce ll P ho ne La nd -li ne Ph on e Au to m ob ile Percentage Urban Rural Co m pu te r VC R 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) <45 45-54 55-69 70-79 80+ * Abkhazia: Autonomous region not under goverment control Percentage of Households with Cell phones, by Region Figure 3.1.6 % Households with Cell Phones <40 40-49 50-59 60+ * REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 16 nificantly, and ownership of a refrigerator or a func- tioning automobile decreased slightly. Table 3.1.3, discussed above, presents the proportion of households with selected characteristics (i.e. avail- ability of basic services, amenities and goods) within each of the five wealth quintiles. As expected, the proportion of households with each specific charac- teristic increases as wealth quintile increases, with the exception of having uncrowded living conditions and a satellite dish. The proportion of uncrowded living con- ditions is best in the lowest two wealth quintiles and worsens considerably in the highest quintiles. Pres- ence of a satellite dish is highest in the middle wealth quintile (31%) and lowest in the highest (16%) quintile. It should be noted that there is very little difference in the availability of 24-hour electricity supply and TV sets among the various wealth quintiles. On the other hand, a dramatic variation appears in the availability of flush toilets, ranging from 0% in the lowest wealth quintile to 100% in the highest wealth quintile. Very large differences also exist in the availability of several other household characteristics, such as energy used for cooking, type of heating system, computer and in- ternet across wealth quintiles. The proportion of respondents living in a privately owned flat or house increased between 2005 and 2010 RHS from 85% to 93%, with the highest rate in Kakheti region (99%) and the lowest in Tbilisi (84%). Living in a rental space and living with immediate fam- ily is more common in urban than in rural areas and the highest proportion is observed in Tbilisi (12% and 3% respectively). The proportion of respondents liv- 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Changes in Availability of Basic Services in the Household: GERHS 1999, 2005, and 2010 Figure 3.1.7 Electricity (24 Hours) 100 80 60 40 20 0 Land-line Phone Central Heating Percent 1999 2005 2010 Flush Toilet 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Changes in Ownership of Goods in the Household: GERHS 1999, 2005, and 2010 Figure 3.1.8 Vacation home 100 80 60 40 20 0 Refrigerator Automobile Percent TV 1999 2005 2010 VCR Cell Phone FINAL REPORT 17 ing with their immediate family decreased since 2005 and constitutes only about 2% of all respondents (see Table 3.1.9 for the 2010 data). A typical household in the 2010 survey has on average 3.8 rooms, excluding the kitchen and bathroom. Rural households have more rooms than urban households do (4.6 vs. 3.0). Respondents living in the Kakheti region report the highest average number of rooms (5.2), followed by Guria, Samegrelo and Imereti re- gions with averages of 4.5 each. The lowest average number of rooms is reported by respondents living in Tbilisi (2.5) (Table 3.1.10). On average there are 3.3 persons per household, more in rural (3.5%) than in urban (3.2%) areas. The aver- age household size is lowest in Racha-Svaneti region (2.8 persons) and highest in Adjara and Samtskhe- Javakheti regions (3.9 and 3.8 persons, respectively). Headship was owned by males in 67% of all house- holds. Household headship by males slightly predomi- nates in rural than in urban areas (71% vs. 64%). The highest prevalence of male headship in households is reported in Adjara and Guria regions (71%), and the lowest prevalence in Tbilisi (64%) (Table 3.1.11). Overcrowding in households can be approximately assessed by dividing the average number of persons (Table 3.1.11) by the average number of rooms (Table 3.1.10) in the household. Overall, there is an average 0.8 persons per room, with 1.1 in urban areas and 0.8 in rural areas. In Tbilisi there are on average 1.3 per- sons per room. According to self-reported data about the family’s material status as collected in the 2010 survey, 67% indicated that they “Can somehow satisfy our needs.” An additional 26% stated that they “Can hardly make ends meet.” Only about 7% declared that they “Can easily satisfy our needs;” most of these live in the Ad- jara region. The proportion of households which “Can hardly make ends meet” is highest in rural areas (35%) and in Guria Region (45%) (Table 3.1.12). 3.2 Characteristics of the Respondents As shown in Table 3.2.1, the respondent age distribu- tion is fairly uniform, both generally and across place of residence. Overall, 36% of the respondents were young adults (aged 15–24) at the time of interview, a percentage that does not vary significantly by resi- dence. Nearly 60% of the respondents were legally married or living in a consensual union; the vast majority were legally married (58%). The percentage of respondents who were married or living in a consensual union was much higher in rural areas (64%) than in Tbilisi (52%) or other urban areas (57%). Slightly more than one-third of the respondents have never been mar- ried or lived with a partner. In Tbilisi the proportion of women who have never been married is the highest (40%). Seven percent of the respondents stated that they had been previously married and were now ei- ther divorced or separated. Figure 3.2.1 provides additional details on marital sta- tus by age groups. The vast majority of women aged 15–19 years have never been married or lived with a partner. Among women 20–24 years of age, one in two (49%) is married or living in a consensual union; by the time women reach 25–29 years of age, 71% are married. The proportion of married respondents con- tinues to increase with age, and by the time women reach 40–44 years of age, 90% have been married. 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Current Marital Status by Age Group among Women Aged 15–44 Figure 3.2.1 25-29 100 80 60 40 20 0 20-24 30-34 Percent 15-19 Never married 35-39 40-44 Age Group Previously married Never married REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 18 The proportion of women who have previously been married increases from 0.8 % among women aged 15–19 years to 13% among women aged 40–44 years (Table 3.2.2). Overall, 41% of all respondents aged 15-44 had no living children at time of interview. Percentages were highest among Tbilisi respondents (47%), and lowest among rural respondents (38%). Almost one in five re- spondents reported having one living child, while 30% reported having two living children, and 10% reported having three or more (Table 3.2.1). As in the 2005 sur- vey, Tbilisi respondents reported having, on average, fewer living children (1.7) than respondents who live in other urban areas (1.8) and in rural areas (2.0) (Fig- ure 3.2.2). Georgian women are well-educated, as evidenced by the fact that only 23% have less than a complete secondary education. In general, respondents living in Tbilisi and other urban areas were better educat- ed than those living in rural areas (Figure 3.2.3). For example, as shown in Table 3.2.1, respondents living in Tbilisi were almost three times more likely than ru- ral respondents to have received university training. The regions with the least educated populations are Kvemo Kartli, Samtskhe-Javakheti, Kakheti, and Guria: only 37%–42% of respondents have 12 or more years of education (Figure 3.2.4). Not surprisingly, respondents living in these regions are the least likely to receive university training and, to a certain degree, technical training. Regarding higher education, the Tbilisi region stands out: 60% of respondents have undergone university training while only 13% have not completed secondary education 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Number of Living Children among Women Aged 15–44, by Residence Figure 3.2.2 2 50 40 30 20 10 0 1 3 Percent 0 Tbilisi Other Urban Rural 4+ Number of Living Children 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Educational Attainment among Women Aged 15–44, by Residence Figure 3.2.3 Other Urban 100 80 60 40 20 0 Tbilisi Rural Percent Total Secondary Complete Technicum University Less than Secondary Complete FINAL REPORT 19 (Table 3.2.1). No other region in the country is within 20 percentage points of achieving the same educa- tional attainment rates as Tbilisi. This disparity is likely due to better access to higher education facilities and faculty in Tbilisi. Slightly more than one-third of the respondents lived in households within the two lowest wealth quin- tiles, while 21% lived in middle-quintile households, and 44% lived in households within the two highest wealth quintiles. The percentage living in the lowest two quintiles was highest for rural respondents (66%) and lowest for Tbilisi respondents (1%). In contrast, only 5% of rural respondents were classified as living in two highest quintiles, while virtually all respond- ents living in Tbilisi were classified as living in those quintiles (Table 3.2.1). Only 21% of the respondents reported working out- side of the home at least 20 hours per week. Rural women were less likely to work outside of the home (13%) than women residing in Tbilisi and urban areas (31% and 26%). The vast majority of the respondents reported themselves to be Georgian (87%), while 5% each reported to be of Azeri and Armenian descent. Respondents belonging to minority ethnic groups were more likely to live in rural areas than in urban areas (19% vs. 8%). The dominant religion is Georgian Orthodox (82%); next is the Muslim religion (11%), with 5% belonging to other Orthodox denominations. As shown in Table 3.2.1, the majority of Muslims live in rural areas, where they constitute 18% of the popu- lation. Table 3.2.2 presents additional details on educa- tional attainment for women aged 15-44. Overall, fewer than one in four (23%) Georgian women have not completed secondary education while 39% are at the university or other postgraduate levels. With the exception of women aged 15–19 years, most of whom presumably are still in school, younger women are somewhat more likely than older women to have a university education. Women aged 40-44 are the most likely to report technical training as their highest education level. In Table 3.2.3 for females aged 6 and older, university and other postgraduate education is more common in urban (45%) than in rural (19%) areas. The highest prevalence of university and post- graduate education is reported in Tbilisi (53%), while the lowest is observed in Guria (15%) region. Educa- tional attainment changes across the wealth quintiles from only 13% of women having higher education in the lowest quintile to 57% of women having univer- sity/postgraduate education in the highest quintile. In Table 3.2.3, for women aged 6 and older, the me- dian years of education completed is 10.8. Table 3.2.4 summarizes the educational attainments of the male household population over age six. Over- all, 25% of men have less than complete secondary education (below 10 years) and 29% have received university or other postgraduate education. The me- dian years of education completed is 10.7, nearly the same as for women. Also, similar to women, the high- est percentage of university or other postgraduate ed- ucation for men is reported in Tbilisi and in the highest wealth quintile, while the lowest percentage is in the Guria region and in the lowest wealth quintile. 3.3. School Entries and Attendance Ratios The series of six tables, Nos. 3.3.1 to 3.3.6, present additional educational information on school entries 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) * Abkhazia: Autonomous region not under goverment control Percentage of Women with Post-secondary Education, by Region Figure 3.2.4 % Households with 12+ Yrs. of Education <45 45-54 55-59 60+ * REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 20 and attendance. These are all from the MICS survey in 2010-11, and the MICS Indicator number appears below each table. They are summarized as follows. Table 3.3.1 One indicator of interest concerns the movement from preschool to first grade. In Geor- gia 40% of children in the first grade attended pre- school in the previous year. Table 3.3.2 Among children at the entry age for grade one, 83% enter (84% for boys and 82% for girls, remarkably nearly the same.) Table 3.3.3 Among all children of primary school age, 96% are attending school (net attendance ratios). That leaves 4% who are out of school when they are expected to be attending. Slightly below the average were Kakheti and Kvemo Kartli, at 93%. Table 3.3.4 The overall secondary school attend- ance ratio is 86%, leaving 14% out of school com- pared to 4% for primary school children. It is probable that some of the 14% are actually attending primary school. Table 3.3.5 The transition rate from primary to secondary school is almost 100%, and it is nearly iden- tical for both girls and boys. Table 3.3.6 The very small difference between the sexes appears in the “gender parity” measure, for both primary and secondary school. Table 3.1.1 Percentage Distribution of Households by Wealth Quintiles by Residence and Region Reproductive Health Survey: Georgia, 2010 Lowest Second Middle Fourth Highest Total 20.0 20.0 20.2 19.8 20.0 100.0 12,904 Residence Urban 3.7 5.0 17.4 35.7 38.1 100.0 5,708 Rural 37.5 36.0 23.1 2.8 0.6 100.0 7,196 Residence Tbilisi 0.4 0.6 7.7 35.4 55.8 100.0 2,636 Other Urban 7.1 9.5 27.1 36.0 20.4 100.0 3,072 Rural 37.5 36.0 23.1 2.8 0.6 100.0 7,196 Region Kakheti 30.3 35.2 30.0 3.6 1.0 100.0 1,024 Tbilisi 0.4 0.6 7.7 35.4 55.8 100.0 2,636 Shida Kartli 25.9 32.9 27.2 9.8 4.2 100.0 817 Kvemo Kartli 23.3 20.5 23.7 18.4 14.0 100.0 1,020 Samtskhe–Javakheti 20.8 29.6 38.6 8.4 2.7 100.0 822 Adjara 14.0 20.6 25.9 26.6 12.9 100.0 621 Guria 50.4 24.9 17.4 6.0 1.2 100.0 1,003 Samegrelo 41.4 29.0 18.7 8.0 3.0 100.0 1,050 Imereti 19.0 23.9 22.2 22.7 12.2 100.0 1,633 Mtskheta–Mtianeti 24.4 29.1 26.6 14.1 5.8 100.0 821 Racha–Svaneti 57.1 27.8 13.6 1.4 0.1 100.0 1,457 Characteristic Wealth Quintile Total No. of Cases FINAL REPORT 21 Ta bl e 3. 1. 2 Ur ba n Ru ra l Ka kh et i Tb ili si Sh id a Ka rtl i Kv em o Ka rtl i Sa m ts kh e– Ja va kh et i Ad ja ra G ur ia Sa m eg re lo Im er et i M ts kh et a– M tia ne ti Ra ch a– Sv an et i El ec tri ci ty 2 4 ho ur s Ye s 96 .4 96 .6 96 .2 98 .3 97 .1 97 .7 91 .9 99 .3 91 .8 97 .9 97 .4 97 .6 90 .9 98 .1 N o 3. 6 3. 4 3. 8 1. 7 2. 9 2. 3 8. 1 0. 7 8. 2 2. 1 2. 6 2. 4 9. 1 1. 9 W at er Pi pe d w at er (p ip ed in to 53 .3 86 .8 17 .4 19 .4 96 .8 30 .7 44 .8 55 .8 63 .0 16 .7 19 .8 49 .1 38 .2 15 .9 Pi pe d w at er (i nt o 22 .7 9. 2 37 .2 42 .3 2. 7 33 .7 23 .9 34 .8 20 .8 23 .8 25 .7 26 .0 36 .3 68 .5 Pi pe d w at er /p ub lic 5. 8 0. 8 11 .2 19 .6 0. 3 11 .6 13 .7 7. 2 2. 9 5. 7 2. 0 2. 1 8. 0 7. 1 Tu be w el l, bo re ho le 1. 2 0. 3 2. 2 1. 6 0. 1 1. 2 0. 5 0. 0 1. 1 3. 0 3. 2 1. 5 3. 3 1. 3 Pr ot ec te d w el l 8. 4 1. 1 16 .2 11 .0 0. 0 5. 8 2. 8 0. 4 1. 1 46 .2 19 .8 16 .0 6. 8 1. 0 U np ro te ct ed w el l 5. 3 1. 5 9. 2 1. 6 0. 0 12 .2 5. 0 0. 0 0. 2 4. 2 29 .2 3. 2 1. 0 1. 2 Pr ot ec te d sp rin g 2. 0 0. 2 4. 1 2. 6 0. 0 2. 4 5. 0 1. 1 7. 9 0. 3 0. 2 1. 5 4. 8 1. 4 U np ro te ct ed s pr in g 0. 8 0. 0 1. 7 1. 1 0. 0 1. 5 3. 3 0. 7 0. 8 0. 2 0. 0 0. 6 0. 7 3. 6 O th er 0. 4 0. 0 0. 8 0. 8 0. 0 0. 9 0. 9 0. 0 2. 3 0. 0 0. 0 0. 1 0. 9 0. 1 To ile t F ac ili tie s Fl us h to ile t p ip ed to s ew er 45 .8 82 .9 6. 0 7. 3 95 .3 19 .8 38 .2 24 .8 54 .1 14 .2 13 .8 41 .7 25 .8 7. 0 Fl us h to ile t p ip ed to 2. 2 1. 3 3. 2 6. 8 1. 1 0. 7 2. 7 1. 9 5. 3 0. 7 0. 5 1. 4 5. 4 1. 4 Ve nt ila te d im pr ov ed p it 1. 9 0. 9 2. 9 2. 7 0. 5 1. 6 2. 6 2. 8 1. 3 1. 0 4. 9 1. 3 1. 7 3. 6 Pi t l at rin e w ith s la b 34 .5 11 .1 59 .6 64 .5 2. 0 54 .8 42 .3 26 .6 12 .7 69 .3 67 .8 36 .6 33 .9 58 .2 Pi t l at rin e w ith ou t s la b 14 .0 3. 4 25 .3 18 .4 1. 0 20 .9 13 .9 38 .7 11 .4 14 .7 13 .0 18 .7 32 .9 29 .6 H an gi ng la tri ne 1 4 0 0 2 9 0 3 0 0 0 0 0 1 4 5 15 1 0 2 0 0 0 2 0 2 0 1 Av ai la bi lit y of B as ic S er vi ce s in th e Ho us eh ol d by R es id en ce a nd R eg io n Re pr od uc tiv e He al th S ur ve y: G eo rg ia , 2 01 0 Ch ar ac te ris tic To ta l Re si de nc e Re gi on H an gi ng la tri ne 1. 4 0. 0 2. 9 0. 3 0. 0 0. 0 0. 1 4. 5 15 .1 0. 2 0. 0 0. 2 0. 2 0. 1 N o fa ci lit y/ Bu sh /F ie ld 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 0. 1 0. 5 0. 0 0. 0 0. 0 0. 0 0. 1 0. 1 O th er 0. 2 0. 4 0. 0 0. 0 0. 1 2. 1 0. 0 0. 1 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 En er gy U se d fo r El ec tri ci ty 3. 7 6. 3 1. 1 0. 4 7. 5 1. 5 2. 9 0. 6 6. 0 1. 2 3. 3 2. 2 3. 8 0. 2 N at ur al g as 44 .8 73 .7 13 .8 26 .2 89 .8 29 .3 51 .8 9. 9 26 .9 8. 1 3. 7 43 .8 33 .0 1. 5 C oa l/W oo d 39 .8 11 .5 70 .1 57 .6 1. 1 55 .7 36 .1 64 .7 39 .3 81 .3 75 .5 40 .7 54 .8 96 .2 O th er 11 .6 8. 5 15 .0 15 .8 1. 6 13 .6 9. 2 24 .8 27 .9 9. 5 17 .4 13 .3 8. 4 2. 1 Ty pe o f H ea tin g Sy st em C en tra l h ea tin g 1. 4 2. 6 0. 1 0. 1 4. 1 0. 5 0. 3 0. 4 1. 6 0. 1 0. 1 0. 4 0. 6 0. 1 O w n bo ile r 0. 8 1. 4 0. 2 0. 2 1. 7 0. 5 1. 0 0. 2 1. 8 1. 2 0. 1 0. 2 0. 5 0. 1 In di vi du al ro om h ea tin g 28 .9 47 .5 9. 0 5. 7 57 .1 23 .9 24 .8 6. 1 27 .5 8. 7 23 .2 21 .6 17 .1 7. 5 St ov e he at in g 66 .5 45 .0 89 .6 93 .0 32 .7 74 .7 71 .5 93 .1 65 .4 89 .5 75 .5 75 .8 80 .3 92 .1 N o he at in g 2. 1 3. 3 0. 8 1. 0 4. 2 0. 5 2. 2 0. 2 1. 9 0. 5 1. 0 1. 7 1. 2 0. 2 O th er 0. 3 0. 2 0. 3 0. 1 0. 1 0. 0 0. 3 0. 0 1. 8 0. 0 0. 0 0. 4 0. 4 0. 0 M ai n Ro of M at er ia l Ti le o r c on cr et e 26 .5 45 .3 6. 5 3. 1 61 .8 8. 8 17 .2 4. 7 18 .7 7. 1 13 .5 22 .2 25 .3 3. 4 C or ru ga te d iro n 36 .0 19 .6 53 .6 42 .7 6. 8 47 .1 48 .7 58 .9 51 .7 69 .7 49 .2 38 .5 34 .0 23 .1 Sh ee t m et al 33 .2 28 .3 38 .3 52 .8 23 .7 42 .8 27 .4 35 .4 27 .5 22 .5 33 .7 36 .1 36 .1 68 .9 As ph al t s hi ng le s 2. 4 4. 5 0. 1 0. 1 5. 2 0. 1 5. 3 0. 0 0. 6 0. 3 0. 9 1. 6 1. 2 1. 0 N at ur al m at er ia ls 1. 3 1. 6 1. 1 0. 7 2. 0 0. 9 0. 6 0. 6 0. 6 0. 2 2. 6 1. 0 2. 2 2. 5 O th er 0. 5 0. 7 0. 4 0. 6 0. 5 0. 2 0. 9 0. 4 0. 8 0. 2 0. 1 0. 7 1. 2 1. 1 No . o f C as es 12 .9 04 5, 70 8 7, 19 6 1, 02 4 2, 63 6 81 7 1, 02 0 82 2 62 1 1, 00 3 1, 05 0 1, 63 3 82 1 1, 45 7 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 22 Ta bl e 3. 1. 4 Pe rc en t D is tr ib ut io n of H ou se ho ld P op ul at io n A cc or di ng to M ai n So ur ce o f D rin ki ng W at er a nd P er ce nt ag e of H ou se ho ld P op ul at io n U si ng Im pr ov ed D rin ki ng W at er S ou rc es , G eo rg ia , 2 01 0- 20 11 Pi pe d w at er (p ip ed in to d w el lin g) Pi pe d w at er (p ip ed in to co m po un d, ya rd o r p lo t) Pi pe d w at er (p ip ed to ne ig hb or ) Pi pe d w at er (p ub lic ta p/ st an dp ip e) Tu be w el l, bo re ho le Pr ot ec te d w el l Pr ot ec te d sp rin g B ot tle d w at er U np ro te ct ed w el l U np ro te c te d sp rin g Ta nk er tr uc ke r C ar ts w ith sm al l ta nk /d ru m Su rf ac e w at er (r iv er , s tr ea m , da m , l ak e, p on d, ca na l, irr ig at io n) O th er R eg io n K ak he ti 19 .4 41 .1 4. 8 15 .7 1. 7 11 .2 2. 8 .0 1. 4 1. 1 .1 .4 .0 .3 10 0. 0 96 .7 4, 07 9 Tb ili si 96 .9 2. 7 .2 .1 .1 .0 .0 .0 .0 .0 .0 .0 .0 .0 10 0. 0 10 0. 0 10 ,5 06 S hi da K ar tli 30 .9 32 .4 1. 7 9. 2 1. 7 6. 1 2. 4 .0 13 .5 1. 3 .0 .0 .0 .7 10 0. 0 84 .5 3, 05 2 K ve m o K ar tli 42 .9 23 .7 1. 3 13 .2 .7 3. 5 5. 2 .4 4. 7 3. 6 .1 .5 .1 .0 10 0. 0 90 .9 4, 69 2 S am ts kh e- Ja va kh et i 56 .1 33 .7 2. 4 5. 5 .0 .4 1. 2 .0 .0 .8 .0 .0 .0 .0 10 0. 0 99 .2 2, 14 8 A dj ar a 59 .4 22 .0 1. 1 2. 5 1. 6 .8 9. 1 .0 .1 .8 .0 .0 .0 2. 6 10 0. 0 96 .5 3, 78 2 G ur ia 16 .8 22 .9 .8 5. 0 3. 1 47 .0 .2 .0 3. 9 .2 .0 .0 .0 .0 10 0. 0 95 .9 1, 41 9 S am eg re lo 18 .8 24 .9 1. 7 .2 3. 5 19 .9 .3 .0 30 .6 .0 .0 .0 .0 .0 10 0. 0 69 .4 4, 34 5 Im er et i 49 .7 25 .1 .9 .9 1. 9 16 .2 1. 6 .0 3. 0 .6 .0 .0 .0 .0 10 0. 0 96 .4 7 , 00 5 M ts kh et a- M tia ne ti 39 .8 33 .8 2. 8 4. 5 3. 7 7. 7 4. 9 .1 1. 2 .9 .0 .5 .1 .0 10 0. 0 97 .3 1, 24 1 R ac ha -S va ne ti 17 .4 67 .4 2. 5 3. 6 .9 1. 1 1. 1 .0 1. 5 4. 3 .0 .1 .0 .0 10 0. 0 94 .1 58 4 R es id en ce U rb an 86 .9 8. 9 .4 .3 .3 1. 3 .2 .0 1. 7 .0 .0 .0 .0 .0 10 0. 0 98 .3 21 ,1 02 R ur al 19 .2 35 .5 2. 5 8. 8 2. 5 15 .3 4. 4 .1 9. 0 1. 8 .0 .2 .0 .6 10 0. 0 88 .4 21 ,7 51 Ed uc at io n of H ou se ho ld H ea d N on e 67 .8 15 .9 .9 3. 2 .9 5. 8 1. 6 .0 3. 0 .5 .0 .1 .0 .3 10 0. 0 96 .1 20 ,8 46 P rim ar y 31 .3 31 .6 2. 5 8. 5 1. 9 7. 9 6. 8 .0 5. 5 3. 7 .0 .2 .0 .0 10 0. 0 90 .6 1, 57 7 S ec on da ry + 38 .6 28 .4 1. 9 5. 8 1. 9 11 .1 2. 7 .1 7. 9 1. 0 .0 .1 .0 .4 10 0. 0 90 .5 20 ,4 24 M is si n g /D K 10 0. 0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 10 0. 0 10 0. 0 5 W ea lth In de x Q ui nt ile s Lo w es t .1 43 .3 2. 8 8. 8 2. 0 20 .1 5. 5 .1 13 .1 3. 1 .0 .1 .0 .8 10 0. 0 82 .7 7 , 63 4 S ec on d 10 .7 43 .7 2. 2 9. 2 2. 8 15 .5 4. 7 .1 8. 9 1. 6 .1 .1 .1 .6 10 0. 0 88 .7 9, 17 5 M id dl e 54 .2 23 .1 1. 9 4. 6 2. 1 6. 8 1. 5 .1 5. 3 .0 .0 .3 .0 .2 10 0. 0 94 .2 9, 18 0 Fo ur th 96 .1 2. 1 .3 .7 .1 .5 .2 .0 .1 .0 .0 .0 .0 .0 10 0. 0 99 .9 7, 62 1 H ig he st 99 .9 .1 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 10 0. 0 10 0. 0 9, 24 2 To ta l 52 .5 22 .4 1. 4 4. 6 1. 4 8. 4 2. 3 .0 5. 4 .9 .0 .1 .0 .3 10 0. 0 93 .2 42 ,8 53 U se o f I m pr ov ed W at er S ou rc es C ha ra ct er is tic [1 ] M IC S in di ca to r 4 .1 ; M D G in di ca to r 7 .8 Pe rc en ta ge us in g im pr ov ed so ur ce s of dr in ki ng w at er [1 ] M ai n so ur ce o f d rin ki ng w at er N um be r o f ho us eh ol d m em be rs Im pr ov ed s ou rc es U ni m pr ov ed s ou rc es To ta l Ur ba n Ru ra l Lo we st Se co nd M id dl e Fo ur th Hi gh es t El ec tri cit y 2 4 ho ur s 96 .4 96 .6 96 .2 94 .6 96 .4 97 .0 96 .0 97 .9 Pi pe d wa te r 76 .0 96 .0 54 .6 45 .3 57 .3 79 .1 98 .6 99 .9 Fl us h to ile t 48 .0 84 .2 9. 3 0. 0 2. 4 40 .6 97 .8 10 0. 0 Co ok ing w ith e lec tri cit y o r n at ur al ga s 48 .6 80 .0 14 .9 0. 2 11 .8 46 .7 87 .7 96 .9 Ce nt ra l o r i nd ivi du al ro om h ea tin g 31 .1 51 .5 9. 3 0. 2 8. 0 18 .8 47 .9 81 .1 Un cr ow de d liv ing co nd itio ns * 66 .5 57 .8 75 .8 76 .1 76 .3 73 .0 61 .4 45 .4 T. V. 96 .6 97 .9 95 .1 89 .3 98 .0 97 .8 98 .0 99 .8 Ce llu lar p ho ne 74 .5 81 .9 66 .5 43 .4 74 .0 79 .2 78 .1 97 .7 Re fri ge ra to r 78 .8 89 .1 67 .9 41 .7 78 .2 85 .2 90 .4 98 .9 Ho us eh old p ho ne 56 .0 72 .5 38 .3 15 .9 41 .3 59 .0 70 .3 93 .7 W or kin g au to m ob ile 25 .2 28 .1 22 .0 3. 2 25 .3 28 .9 20 .9 47 .3 Co m pu te r 21 .0 35 .2 5. 8 0. 0 1. 1 11 .7 18 .8 73 .7 In te rn et 19 .7 34 .0 4. 4 0. 0 0. 6 8. 8 17 .6 71 .7 VC R/ DV D 18 .6 26 .0 10 .6 0. 6 9. 3 17 .6 19 .5 45 .8 Sa te llit e dis h 21 .3 13 .9 29 .2 17 .6 29 .0 30 .7 13 .0 16 .1 Va ca tio n ho m e (v illa ) 6. 9 12 .2 1. 2 0. 2 1. 0 1. 8 4. 2 27 .3 Ai r c on dit ion er 3. 8 6. 9 0. 5 0. 0 0. 1 0. 4 1. 6 17 .2 No . o f C as es 12 ,9 04 5, 70 8 7, 19 6 3, 31 2 2, 81 5 2, 60 3 2, 12 1 2, 05 3 Ta bl e 3. 1. 3 A va ila bi lit y of B as ic S er vi ce s in th e Ho us eh ol d by R es id en ce a nd W ea lth Q ui nt ile . Re pr od uc tiv e He al th S ur ve y: G eo rg ia , 2 01 0 * T h t t l b f li i i th h h ld di id d b th t t l b f ( t i ld i ki th d b th ) l Ch ar ac te ris tic To ta l Re si de nc e W ea lth Q ui nt ile * T he to ta l n um be r o f p er so ns liv ing in th e ho us eh old d ivi de d by th e to ta l n um be r o f r oo m s ( no t in clu din g kit ch en a nd b at hr oo m ) w as o ne o r l es s. FINAL REPORT 23 Ta bl e 3. 1. 5 T im e to S ou rc e of D rin ki ng W at er Pe rc en t D is tri bu tio n of H ou se ho ld P op ul at io n Ac co rd in g to T im e to G o to S ou rc e of D rin ki ng W at er , G et W at er , a nd R et ur n, fo r U se rs o f I m pr ov ed a nd U ni m pr ov ed D rin ki ng W at er S ou rc es , G eo rg ia , 2 01 0- 20 11 C ha ra ct er is tic W at er o n pr em is es Le ss th an 3 0 m in ut es 30 m in ut es o r m or e Le ss th an 3 0 m in ut es 30 m in ut es o r m or e R e g io n Ka kh et i 65 .3 28 .0 3. 4 2. 0 1. 3 10 0. 0 4, 07 9 Tb ilis i 99 .8 .2 .0 .0 .0 10 0. 0 10 ,5 06 Sh id a Ka rtl i 65 .0 18 .5 1. 0 14 .8 .8 10 0. 0 3, 05 2 Kv em o Ka rtl i 68 .2 14 .2 8. 5 6. 2 2. 9 10 0. 0 4, 69 2 Sa m ts kh e- Ja va kh et i 92 .1 5. 8 1. 2 .8 .0 10 0. 0 2, 14 8 Ad ja ra 82 .5 6. 1 7. 8 1. 3 2. 3 10 0. 0 3, 78 2 G ur ia 40 .5 51 .8 3. 6 3. 8 .3 10 0. 0 1, 41 9 Sa m eg re lo 45 .4 23 .0 1. 0 30 .2 .4 10 0. 0 4, 34 5 Im er et i 75 .8 18 .4 2. 2 2. 5 1. 2 10 0. 0 7, 00 5 M ts kh et a- M tia ne ti 76 .5 17 .8 3. 0 2. 1 .6 10 0. 0 1, 24 1 R ac ha -S va ne ti 87 .3 5. 9 .8 5. 8 .1 10 0. 0 58 4 Re si de nc e U rb an 96 .1 1. 9 .2 1. 5 .2 10 0. 0 21 ,1 02 R ur al 57 .3 25 .8 5. 3 9. 9 1. 7 10 0. 0 21 ,7 51 Ed uc at io n of H ou se ho ld H ea d N on e 84 .6 9. 7 1. 8 3. 3 .6 10 0. 0 20 ,8 46 Pr im ar y 65 .5 18 .1 7. 0 7. 0 2. 4 10 0. 0 1, 57 7 Se co nd ar y + 68 .9 18 .1 3. 4 8. 3 1. 2 10 0. 0 20 ,4 24 M is si ng /D K 10 0. 0 .0 .0 .0 .0 10 0. 0 5 W ea lth In de x Q ui nt ile s Lo w es t 46 .3 30 .3 6. 1 14 .5 2. 8 10 0. 0 7, 63 4 Se co nd 56 .6 26 .8 5. 2 9. 9 1. 4 10 0. 0 9, 17 5 M id dl e 79 .2 12 .6 2. 4 5. 1 .7 10 0. 0 9, 18 0 Fo ur th 98 .5 1. 1 .3 .1 .0 10 0. 0 7, 62 1 H ig he st 99 .9 .1 .0 .0 .0 10 0. 0 9, 24 2 To ta l 76 .4 14 .1 2. 8 5. 8 1. 0 10 0. 0 42 ,8 53 Ti m e to s ou rc e of d rin ki ng w at er To ta l N o. of h ou se ho ld m em be rs Us er s of im pr ov ed d rin ki ng w at er s ou rc es Us er s of u ni m pr ov ed d rin ki ng w at er so ur ce s Ta bl e 3. 1. 6 T yp es o f S an ita tio n Fa ci lit ie s P er ce nt D is tri bu tio n of H ou se ho ld P op ul at io n Ac co rd in g to T yp e of T oi le t F ac ili ty U se d by th e Ho us eh ol d, G eo rg ia , 2 01 0- 20 11 Fl us h to ile t p ip ed to se we r s ys te m Fl us h to ile t p ip ed to s ep tic ta nk Fl us h to ile t p ip ed to p it (la tri ne ) Fl us h to ile t p ip ed un kn ow n pl ac e/ no t su re /d k wh er e Ve nt ila te d im pr ov ed p it la tri ne Pi t l at rin e wi th sl ab Co m po st in g to ile t Fl us h to ile t p ip ed to s om ew he re e ls e Pi t l at rin e wi th ou t sl ab Bu ck et Ha ng in g to ile t, ha ng in g la tri ne Ot he r No fa ci lit y/ bu sh /fi el d Re gi on Ka kh et i 5. 2 1. 4 3. 6 1. 9 2. 0 65 .5 .3 2. 1 18 .0 .0 .0 .0 .0 10 0. 0 4, 07 9 Tb ilis i 94 .8 .5 .7 .1 .5 2. 2 .0 .1 1. 0 .0 .0 .1 .0 10 0. 0 10 ,5 06 Sh id a Ka rtl i 18 .5 1. 1 .6 .1 1. 7 57 .0 .0 .1 19 .2 .0 .0 1. 5 .0 10 0. 0 3 , 05 2 Kv em o Ka rtl i 32 .9 2. 9 2. 3 .1 3. 1 44 .9 .1 .3 13 .4 .0 .0 .0 .0 10 0. 0 4 , 69 2 Sa m ts kh e- Ja va kh et i 20 .9 .4 1. 1 .0 3. 4 27 .6 .0 .9 40 .0 .0 5. 4 .1 .2 10 0. 0 2 , 14 8 Ad ja ra 47 .9 2. 0 1. 4 1. 9 1. 4 12 .9 2. 0 1. 6 12 .5 .0 16 .3 .0 .0 10 0. 0 3, 78 2 G ur ia 12 .4 1. 6 .4 .3 1. 0 68 .8 .2 .2 15 .0 .0 .0 .0 .0 10 0. 0 1 , 41 9 Sa m e g re lo 11 .3 1. 3 .3 .1 5. 2 68 .0 .0 .0 13 .8 .0 .0 .0 .0 10 0. 0 4, 34 5 Im er et i 38 .2 2. 9 .5 .1 1. 2 38 .2 .4 .9 17 .6 .0 .0 .0 .0 10 0. 0 7 , 00 5 M ts kh et a- M tia ne ti 24 .7 2. 0 4. 2 .0 1. 7 35 .1 .4 .7 31 .1 .0 .0 .0 .0 10 0. 0 1 , 24 1 Ra ch a- Sv an et i 6. 0 1. 3 1. 1 .1 3. 0 59 .6 .2 .2 28 .5 .0 .0 .0 .0 10 0. 0 58 4 Re si de nc e Ur ba n 81 .9 1. 0 .9 .1 .9 11 .5 .0 .2 3. 2 .0 .0 .3 .0 10 0. 0 21 ,1 02 Ru ra l 4. 3 2. 1 1. 6 .7 2. 9 58 .8 .6 1. 0 24 .4 .0 3. 4 .0 .0 10 0. 0 21 ,7 51 Ed uc at io n of H ou se ho ld H ea d No ne 59 .8 1. 9 1. 0 .3 1. 3 25 .2 .3 .4 9. 2 .0 .5 .1 .0 10 0. 0 20 ,8 46 Pr im ar y 13 .1 2. 4 2. 0 2. 6 1. 4 44 .4 1. 6 .5 21 .8 .0 9. 9 .2 .1 10 0. 0 1, 57 7 Se co nd ar y + 27 .2 1. 2 1. 4 .4 2. 6 45 .3 .2 .9 18 .2 .0 2. 3 .2 .0 10 0. 0 20 ,4 24 M iss in g/ DK 10 0. 0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 10 0. 0 5 W ea lth In de x Qu in til es Lo we st .0 .0 .0 .0 2. 6 63 .8 .9 .0 30 .5 .0 1. 9 .1 .0 10 0. 0 7, 63 4 Se co nd .2 .2 .4 .9 2. 7 65 .1 .3 .3 24 .9 .0 4. 8 .2 .0 10 0. 0 9 , 17 5 M id dl e 23 .0 3. 8 3. 8 1. 0 3. 5 45 .9 .3 2. 1 14 .7 .0 1. 6 .3 .0 10 0. 0 9 , 18 0 Fo ur th 91 .2 3. 3 1. 6 .2 .6 2. 0 .0 .6 .3 .0 .0 .1 .0 10 0. 0 7 , 62 1 Hi gh es t 98 .9 .7 .4 .0 .0 .1 .0 .0 .0 .0 .0 .0 .0 10 0. 0 9, 24 2 To ta l 42 .5 1. 6 1. 3 .4 1. 9 35 .5 .3 .6 14 .0 .0 1. 7 .1 .0 10 0. 0 42 ,8 53 N um be r o f ho us eh ol d m em be rs Im pr ov ed s an ita tio n fa ci lit y Un im pr ov ed s an ita tio n fa ci lit y C ha ra ct er is tic Ty pe o f t oi le t f ac ili ty u se d by h ou se ho ld To ta l REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 24 Ta bl e 3. 1. 7 D rin ki ng W at er a nd S an ita tio n La dd er s P er ce nt ag e of H ou se ho ld P op ul at io n by D rin ki ng W at er a nd S an ita tio n La dd er s, G eo rg ia , 2 01 0- 20 11 Pi pe d in to d w el lin g, p lo t o r y ar d O th er im pr ov ed Un im pr ov ed fa ci lit ie s O pe n de fe ca tio n Re gi on Ka kh et i 60 .5 36 .2 3. 3 10 0. 0 79 .9 20 .1 .0 10 0. 0 79 .1 4, 07 9 Tb ilis i 99 .6 .4 .0 10 0. 0 98 .8 1. 2 .0 10 0. 0 98 .8 10 ,5 06 Sh id a Ka rtl i 63 .3 21 .2 15 .5 10 0. 0 79 .2 20 .8 .0 10 0. 0 68 .9 3, 05 2 Kv em o Ka rtl i 66 .6 24 .3 9. 1 10 0. 0 86 .2 13 .7 .0 10 0. 0 78 .2 4, 69 2 Sa m ts kh e- Ja va kh et i 89 .7 9. 4 .8 10 0. 0 53 .3 46 .5 .2 10 0. 0 52 .6 2, 14 8 Ad ja ra 81 .4 15 .0 3. 5 10 0. 0 69 .5 30 .5 .0 10 0. 0 68 .4 3, 78 2 G ur ia 39 .7 56 .3 4. 1 10 0. 0 84 .8 15 .2 .0 10 0. 0 81 .0 1, 41 9 Sa m e g re lo 43 .8 25 .6 30 .6 10 0. 0 86 .2 13 .8 .0 10 0. 0 61 .1 4, 34 5 Im er et i 74 .9 21 .5 3. 6 10 0. 0 81 .5 18 .5 .0 10 0. 0 79 .9 7, 00 5 M ts kh et a- M tia ne ti 73 .6 23 .7 2. 7 10 0. 0 68 .2 31 .8 .0 10 0. 0 66 .5 1, 24 1 Ra ch a- Sv an et i 84 .8 9. 2 5. 9 10 0. 0 71 .2 28 .7 .0 10 0. 0 68 .5 58 4 Re si de nc e Ur ba n 95 .7 2. 5 1. 7 10 0. 0 96 .3 3. 7 .0 10 0. 0 95 .0 21 ,1 02 Ru ra l 54 .8 33 .6 11 .6 10 0. 0 71 .1 28 .8 .0 10 0. 0 62 .9 21 ,7 51 Ed uc at io n of H ou se ho ld H ea d No ne 83 .6 12 .5 3. 9 10 0. 0 89 .8 10 .2 .0 10 0. 0 87 .1 20 ,8 46 Pr im ar y 63 .0 27 .6 9. 4 10 0. 0 67 .5 32 .4 .1 10 0. 0 61 .7 1, 57 7 Se co nd ar y + 67 .0 23 .5 9. 5 10 0. 0 78 .3 21 .7 .0 10 0. 0 71 .4 20 ,4 24 M iss in g/ DK 10 0. 0 .0 .0 10 0. 0 10 0. 0 .0 .0 10 0. 0 10 0. 0 5 W ea lth In de x Q ui nt ile s Lo we s t 43 .4 39 .3 17 .3 10 0. 0 67 .4 32 .6 .0 10 0. 0 56 .3 7, 63 4 Se co nd 54 .4 34 .3 11 .3 10 0. 0 69 .7 30 .2 .0 10 0. 0 61 .5 9, 17 5 M id dl e 77 .3 16 .9 5. 8 10 0. 0 81 .3 18 .7 .0 10 0. 0 76 .3 9, 18 0 Fo ur th 98 .2 1. 8 .1 10 0. 0 98 .9 1. 1 .0 10 0. 0 98 .8 7, 62 1 Hi gh es t 99 .9 .1 .0 10 0. 0 10 0. 0 .0 .0 10 0. 0 10 0. 0 9, 24 2 To ta l 74 .9 18 .3 6. 8 10 0. 0 83 .5 16 .5 .0 10 0. 0 78 .7 42 ,8 53 Un im pr ov ed s an ita tio n To ta l Im pr ov ed d rin ki ng w at er s ou rc es a nd im pr ov ed s an ita tio n [1 ] M IC S in di ca to r 4 .1 ; M DG in di ca to r 7 .8 [2 ] M IC S in di ca to r 4 .3 ; M DG in di ca to r 7 .9 Ch ar ac te ris tic Pe rc en ta ge o f h ou se ho ld p op ul at io n us in g: N um be r o f ho us eh ol ds Im pr ov ed d rin ki ng w at er [1 ] Un im pr ov ed dr in ki ng w at er To ta l Im pr ov ed sa ni ta tio n [2 ] Ta bl e 3 .1. 8 Av ail ab ilit y o f V ar io us H ou se ho ld A m en iti es an d Go od s i n th e H ou se ho ld b y R es id en ce an d Re gi on Re pr od uc tiv e H ea lth S ur ve y: G eo rg ia, 20 10 Ur ba n Ru ra l Ka kh et i Tb ilis i Sh id a Ka rtl i Kv em o Ka rtl i Sa m ts kh e- Ja va kh et i Ad jar a Gu ria Sa m eg re lo Im er et i Mt sk he ta - Mt ian et i Ra ch a- Sv an et i T. V. 96 .6 97 .9 95 .1 97 .0 97 .9 96 .1 94 .5 96 .2 96 .3 97 .5 95 .9 97 .7 91 .6 90 .7 Ce llu lar ph on e 74 .5 81 .9 66 .5 73 .8 85 .7 65 .4 70 .3 79 .2 73 .3 62 .4 64 .2 74 .0 71 .7 57 .4 Re frig er ato r 78 .8 89 .1 67 .9 76 .8 92 .3 72 .7 73 .4 73 .1 81 .0 58 .9 72 .2 77 .7 69 .5 57 .2 Ho us eh old ph on e 56 .0 72 .5 38 .3 44 .3 81 .9 42 .7 47 .7 47 .2 39 .0 49 .0 36 .7 62 .0 34 .1 35 .9 W or kin g a uto mo bil e 25 .2 28 .1 22 .0 28 .1 30 .7 17 .4 24 .2 31 .3 21 .4 16 .2 21 .0 25 .0 22 .4 12 .5 Co mp ute r 21 .0 35 .2 5.8 8.2 47 .0 7.8 15 .0 13 .0 19 .5 4.5 7.5 15 .6 10 .6 3.1 Int er ne t 19 .7 34 .0 4.4 7.1 46 .0 7.1 13 .4 10 .5 19 .2 3.9 6.2 13 .6 7.9 2.1 VC R/ DV D 18 .6 26 .0 10 .6 12 .1 31 .0 7.8 18 .3 30 .4 19 .2 6.4 9.2 14 .6 13 .8 5.2 Sa tel lite di sh 21 .3 13 .9 29 .2 29 .0 8.3 15 .8 33 .2 65 .0 39 .3 12 .7 18 .1 13 .2 30 .3 37 .7 Va ca tio n h om e ( vil la) 6.9 12 .2 1.2 0.8 17 .5 1.6 3.5 1.8 8.7 1.8 1.7 4.4 2.1 1.1 Ai r c on dit ion er 3.8 6.9 0.5 0.3 9.4 0.6 2.0 0.5 7.7 0.3 0.9 2.3 1.5 0.0 N f C 12 90 4 57 08 71 96 10 24 26 36 81 7 10 20 82 2 62 1 10 03 10 50 16 33 82 1 14 57 Ch ar ac te ris tic To ta l Re sid en ce Re gi on No . o f C as es 12 ,90 4 5,7 08 7,1 96 1,0 24 2,6 36 81 7 1,0 20 82 2 62 1 1,0 03 1,0 50 1,6 33 82 1 1,4 57 FINAL REPORT 25 Ta bl e 3. 1. 9 Ty pe o f L iv in g Ar ra ng em en ts b y Re si de nc e an d Re gi on Re pr od uc tiv e He al th S ur ve y: G eo rg ia , 2 01 0 Ur ba n Ru ra l Ka kh et i Tb ili si Sh id a Ka rtl i Kv em o Ka rtl i Sa m ts kh e- Ja va kh et i Ad ja ra Gu ria Sa m eg re lo Im er et i M ts kh et a- M tia ne ti Ra ch a- Sv an et i Liv es in p riv at ely o wn ed fla t o r h ou se 93 .3 88 .9 97 .9 98 .7 84 .1 93 .3 95 .8 97 .8 95 .2 98 .2 95 .5 97 .6 94 .4 98 .4 Liv es in re nt al sp ac e (ro om , f lat , o r h ou se ) 4. 4 8. 0 0. 5 1. 0 11 .9 0. 7 2. 6 0. 9 4. 2 0. 6 2. 1 1. 3 2. 1 0. 8 Liv es w ith im m ed iat e fa m ily 1. 5 2. 2 0. 8 0. 1 2. 8 4. 4 0. 8 0. 5 0. 0 0. 7 1. 7 0. 7 1. 0 0. 6 Liv es w ith o th er re lat ive s 0. 3 0. 3 0. 3 0. 2 0. 4 0. 0 0. 4 0. 5 0. 3 0. 2 0. 4 0. 2 1. 1 0. 1 Ot he r 0. 5 0. 6 0. 4 0. 0 0. 8 1. 6 0. 4 0. 4 0. 3 0. 3 0. 3 0. 2 1. 5 0. 1 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 No . o f C as es 12 ,9 04 5, 70 8 7, 19 6 1, 02 4 2, 63 6 81 7 1, 02 0 82 2 62 1 1, 00 3 1, 05 0 1, 63 3 82 1 1, 45 7 Ty pe o f L iv in g Ar ra ng em en ts To ta l Re si de nc e Re gi on Ta bl e 3. 1. 10 Nu m be r o f R oo m s in th e Ho us eh ol d by R es id en ce a nd R eg io n Re pr od uc tiv e He al th S ur ve y: G eo rg ia , 2 01 0 Ur ba n Ru ra l Ka kh et i Tb ili si Sh id a Ka rtl i Kv em o Ka rtl i Sa m ts kh e- Ja va kh et i Ad ja ra Gu ria Sa m eg re lo Im er et i M ts kh et a- M tia ne ti Ra ch a- Sv an et i 1 8. 5 14 .0 2. 6 1. 3 19 .5 7. 5 7. 7 3. 2 5. 6 2. 5 3. 3 4. 2 8. 9 2. 7 2 20 .1 28 .2 11 .4 7. 5 34 .2 17 .9 21 .1 14 .4 21 .9 13 .4 10 .7 14 .1 21 .7 13 .5 3 22 .5 27 .8 17 .0 12 .0 28 .8 20 .9 23 .9 27 .7 25 .0 14 .3 18 .5 20 .3 23 .4 21 .6 4 20 .4 15 .8 25 .3 23 .1 13 .2 24 .1 23 .0 26 .4 21 .4 27 .3 24 .0 19 .6 23 .8 29 .8 5 10 .4 6. 1 15 .0 14 .8 2. 7 11 .8 11 .2 13 .6 11 .4 14 .5 15 .5 12 .9 9. 0 17 .4 6 8. 5 4. 0 13 .4 18 .6 1. 3 6. 6 7. 4 8. 2 7. 2 15 .1 12 .0 13 .1 5. 8 10 .3 7 or m or e 9. 5 4. 1 15 .3 22 .7 0. 4 11 .3 5. 7 6. 6 7. 4 13 .1 16 .0 15 .8 7. 4 4. 8 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 Av er ag e No . o f R oo m s 3. 8 3. 0 4. 6 5. 2 2. 5 3. 9 3. 6 3. 9 3. 7 4. 5 4. 5 4. 5 3. 6 4. 0 N o. o f C as es 1 2, 90 4 5, 70 8 7, 19 6 1, 02 4 2, 63 6 81 7 1, 02 0 82 2 62 1 1, 00 3 1, 05 0 1, 63 3 82 1 1, 45 7 * N ot in clu din g kit ch en a nd b at hr oo m Nu m be r o f R oo m s* To ta l Re si de nc e Re gi on REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 26 Ta bl e 3. 1. 11 Nu m be r o f P er so ns L iv in g in th e Ho us eh ol d by R es id en ce a nd R eg io n Re pr od uc tiv e He al th S ur ve y: G eo rg ia , 2 01 0 Ur ba n Ru ra l Ka kh et i Tb ili si Sh id a Ka rtl i Kv em o Ka rtl i Sa m ts kh e- Ja va kh et i Ad ja ra Gu ria Sa m eg re lo Im er et i M ts kh et a- M tia ne ti Ra ch a- Sv an et i Ho us eh ol d He ad sh ip M ale 67 .2 64 .1 70 .6 69 .3 64 .0 67 .7 67 .6 69 .1 71 .8 71 .4 67 .8 66 .9 67 .6 67 .0 Fe m ale 32 .8 35 .9 29 .4 30 .7 36 .0 32 .3 32 .4 30 .9 28 .2 28 .6 32 .2 33 .1 32 .4 33 .0 Nu m be r o f P er so ns 1 17 .5 18 .7 16 .1 19 .7 18 .7 16 .4 17 .1 12 .8 10 .0 17 .1 15 .9 19 .2 18 .6 28 .0 2 21 .1 21 .1 21 .1 18 .3 19 .9 24 .1 21 .1 20 .3 14 .0 26 .4 22 .6 24 .1 20 .7 25 .9 3 18 .0 20 .3 15 .5 16 .1 22 .0 15 .5 13 .9 12 .5 17 .6 18 .0 19 .5 17 .0 17 .8 18 .0 4 18 .6 19 .6 17 .4 18 .3 19 .9 17 .0 20 .6 19 .2 20 .9 15 .6 16 .9 17 .5 16 .8 10 .8 5 12 .5 10 .9 14 .1 13 .5 10 .6 14 .7 12 .6 15 .6 16 .3 11 .5 14 .0 10 .7 13 .4 8. 9 6 7. 7 6. 0 9. 5 9. 5 5. 5 7. 7 9. 1 10 .6 14 .0 6. 9 5. 5 7. 2 8. 4 4. 5 7 or m or e 4. 8 3. 4 6. 2 4. 7 3. 3 4. 5 5. 6 9. 0 7. 2 4. 5 5. 6 4. 2 4. 3 3. 8 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 Av er ag e No . o f P er so ns 3. 3 3. 2 3. 5 3. 4 3. 2 3. 3 3. 4 3. 8 3. 9 3. 2 3. 3 3. 2 3. 3 2. 8 No . o f C as es 12 ,9 04 5, 70 8 7, 19 6 1, 02 4 2, 63 6 81 7 1, 02 0 82 2 62 1 1, 00 3 1, 05 0 1, 63 3 82 1 1, 45 7 To ta l Re si de nc e Re gi on Ta bl e 3 .1. 12 Se lf- Re po rte d Ev alu at io n of th e M at er ial S ta tu s o f t he F am ily b y R es id en ce an d Re gi on : Ho us eh ol ds W ith W om en A ge d 15 –4 4 Re pr od uc tiv e H ea lth S ur ve y: G eo rg ia, 20 10 Ur ba n Ru ra l Ka kh et i Tb ilis i Sh id a Ka rtl i Kv em o Ka rtl i Sa m ts kh e- Ja va kh et i Ad jar a Gu ria Sa m eg re lo Im er et i Mt sk he ta - Mt ian et i Ra ch a- Sv an et i Ca n ea sil y s at isf y o ur n ee ds 6. 7 9. 2 3. 8 2. 5 9. 7 4. 1 3. 3 2. 8 12 .8 1. 2 3. 2 8. 6 0. 8 4. 4 Ca n so m eh ow sa tis fy ou r n ee ds 67 .3 72 .9 60 .8 72 .5 75 .1 62 .7 60 .9 71 .0 54 .4 53 .4 69 .4 67 .7 58 .2 56 .8 Ca n ha rd ly m ak e en ds m ee t 25 .7 17 .4 35 .1 24 .5 14 .7 33 .1 35 .9 25 .9 32 .1 45 .0 27 .4 23 .5 41 .1 38 .7 Do es n ot kn ow 0. 3 0. 4 0. 2 0. 5 0. 5 0. 0 0. 0 0. 3 0. 7 0. 4 0. 0 0. 2 0. 0 0. 0 To ta l 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 No . o f C as es 6,2 92 2,9 75 3,3 17 49 8 1,4 26 39 2 54 6 48 1 41 9 40 1 47 7 80 5 39 3 45 4 Ma te ria l S ta tu s o f t he F am ily To ta l Re sid en ce Re gi on FINAL REPORT 27 Table 3.2.1 Characteristics of Eligible Women with Completed Interviews by Residence Tbilisi Other Urban Rural Age Group 15–19 17.9 17.2 17.7 18.6 20–24 18.9 20.3 18.9 18.0 25–29 16.6 16.3 16.3 17.0 30–34 16.3 17.2 16.2 15.9 35–39 15.8 14.9 16.3 16.1 40–44 14.4 14.1 14.5 14.5 Marital Status Legally married 57.9 50.2 57.2 62.8 Consensual union 1.2 1.4 1.3 1.2 Previously married 6.5 8.7 7.2 4.8 Never married 34.4 39.8 34.2 31.2 Number of Living Children 0 41.3 46.8 41.6 37.9 1 19.0 21.8 20.7 16.5 2 29.5 25.3 29.7 31.8 3 8.3 5.1 6.5 11.2 4 or more 1.9 1.1 1.5 2.6 Education Level Secondary incomplete or less 22.6 12.6 17.8 31.2 Characteristic Total Residence Reproductive Health Survey: Georgia, 2010 Secondary incomplete or less 22.6 12.6 17.8 31.2 Secondary complete 24.7 17.5 21.7 30.6 Technicum 13.2 10.0 14.1 14.6 University/Postgraduate 39.4 60.0 46.5 23.6 Wealth Quintile Lowest 14.6 0.5 3.5 28.9 Second 19.5 0.3 7.6 37.3 Middle 21.5 4.6 26.0 28.9 Fourth 18.5 27.9 34.9 4.0 Highest 25.9 66.7 27.9 0.9 Employment Working 21.3 30.9 25.7 13.3 Not working 78.7 69.1 74.3 86.7 Ethnicity Georgian 86.9 91.3 92.5 81.2 Azeri 5.2 0.9 2.3 9.3 Armenian 5.2 4.2 2.8 7.0 Other 2.8 3.6 2.4 2.5 Religion Georgian Orthodox 82.4 92.1 89.2 73.0 Other Orthodox 4.9 4.8 3.3 6.0 Muslim 10.5 1.0 6.2 18.4 Other 1.6 1.7 0.9 2.0 No Religion 0.5 0.4 0.5 0.6 Total 100.0 100.0 100.0 100.0 No. of Cases 6,292 1,426 1,549 3,317 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 28 Table 3.2.2 Percentage Distribution of Women Aged 15–44 by Age, Marital Status and Education Reproductive Health Survey: Georgia, 2010 Legally Married ConsensualUnion Previously Married Never Married 15–19 10.3 0.3 0.8 88.5 100.0 861 20–24 47.1 1.6 3.2 48.2 100.0 1,099 25–29 69.5 1.5 4.2 24.8 100.0 1,191 30–34 77.0 1.0 8.8 13.1 100.0 1,168 35–39 77.4 1.8 10.8 10.1 100.0 1,051 40–44 75.0 1.4 13.2 10.5 100.0 922 Total 57.9 1.2 6.5 34.4 100.0 6,292 Secondary Incomplete or Less Secondary Complete Technicum University/ Postgraduate 15–19 57.4 29.6 2.4 10.7 100.0 861 20 24 12 7 31 4 12 7 43 3 100 0 1 099 Age Group Education Total No. of Cases Age Group Marital Status Total No. of Cases 20–24 12.7 31.4 12.7 43.3 100.0 1,099 25–29 14.1 24.9 11.9 49.2 100.0 1,191 30–34 16.7 22.8 14.0 46.5 100.0 1,168 35–39 16.8 22.4 14.6 46.2 100.0 1,051 40–44 15.5 14.5 26.5 43.5 100.0 922 Total 22.6 24.7 13.2 39.4 100.0 6,292 FINAL REPORT 29 Table 3.2.3 Educational Attainment of the Female Household Population Percent Distribution of the De Facto Female Household Population Age Six and Over By Highest Level of Schooling Attended and Median Years of Schooling Completed, by Selected Characteristics Reproductive Health Survey: Georgia, 2010 No Education Preschool Primary(Grades 1–6) Lower Secondary (Grades 7–9) Upper Secondary (Grades 10–12) Vocational Higher Total 2.8 1.8 8.8 11.5 31.0 11.9 32.2 100.0 21,117 10.8 Age Group 3–9 23.5 24.8 51.6 0.1 0.0 0.0 0.0 100.0 1,466 1.0 10–14 0.6 0.0 45.7 52.0 1.7 0.0 0.0 100.0 1,263 5.5 15–19 0.9 0.0 0.8 14.9 63.3 3.6 16.6 100.0 1,415 10.1 20–24 1.2 0.0 1.0 5.3 30.4 10.8 51.4 100.0 1,444 12.1 25–29 0.8 0.0 1.5 7.3 28.0 10.2 52.1 100.0 1,380 13.1 30–34 1.1 0.1 0.6 8.2 27.2 12.0 50.7 100.0 1,331 12.5 35–39 0.7 0.0 0.6 6.3 29.0 12.0 51.4 100.0 1,303 12.7 40–44 0.5 0.0 0.4 4.8 24.0 19.7 50.6 100.0 1,278 12.4 45–49 0.9 0.0 0.3 4.2 35.3 20.9 38.3 100.0 1,783 11.5 50–54 1.3 0.1 1.4 6.1 35.3 18.5 37.4 100.0 1,686 11.4 55–59 1.3 0.0 1.5 7.6 36.0 19.3 34.2 100.0 1,407 11.2 60–64 1.5 0.0 3.6 9.2 37.0 15.5 33.1 100.0 1,267 11.0 65–69 1.4 0.0 4.0 14.2 39.7 13.0 27.7 100.0 920 10.5 70–74 1.6 0.0 6.7 18.1 42.8 12.3 18.5 100.0 1,416 9.9 75–79 3.2 0.3 9.8 20.7 39.0 10.0 17.0 100.0 803 9.7 80 or more 4.6 0.0 17.0 22.6 31.5 6.5 17.8 100.0 955 9.4 Residence Urban 1.7 2.4 7.3 7.2 24.1 12.0 45.4 100.0 9,279 11.7 Rural 4.1 1.2 10.3 16.0 38.2 11.7 18.6 100.0 11,838 10.0 Region Kakheti 7.7 1.7 10.3 17.2 32.5 12.6 18.1 100.0 1,694 10.0 Tbilisi 1.6 2.3 6.9 5.8 19.5 10.1 53.8 100.0 4,308 13.0 Shida Kartli 2.2 1.1 9.2 10.5 37.1 12.0 27.9 100.0 1,367 10.4 Kvemo Kartli 4.4 1.7 13.2 16.3 31.3 10.1 23.1 100.0 1,752 9.9 Samtskhe–Javakheti 3.2 1.2 10.2 11.9 40.4 9.6 23.5 100.0 1,555 9.8 Adjara 3.6 0.9 11.3 14.4 32.7 12.7 24.5 100.0 1,209 11.1 Guria 1.9 1.3 7.2 20.5 34.4 19.6 15.1 100.0 1,574 9.9 Samegrelo 2.1 1.3 6.4 11.2 43.4 10.1 25.5 100.0 1,728 10.4 Imereti 1.5 2.5 7.4 10.7 32.9 14.3 30.7 100.0 2,602 10.7 Mtskheta–Mtianeti 3.0 2.3 9.9 12.6 30.4 17.1 24.7 100.0 1,334 10.6 Racha–Svaneti 2.5 0.9 9.7 14.4 37.8 10.8 24.0 100.0 1,994 10.1 Wealth Quintile Lowest 5.2 0.7 11.0 20.3 39.9 9.9 13.1 100.0 4,748 9.6 Second 4.0 1.3 10.2 14.3 39.7 11.9 18.6 100.0 4,806 10.1 Middle 2.2 2.0 9.2 11.4 33.9 13.6 27.7 100.0 4,507 10.5 Fourth 1.9 2.4 6.8 7.2 26.0 14.3 41.3 100.0 3,341 11.5 Highest 1.3 2.5 6.9 5.3 17.0 9.6 57.4 100.0 3,715 14.0 * Excludes 2 women for whom the highest level of school attendance was unknown. Total No. of Cases* Median Years CompletedCharacteristic Highest Level of School Attended REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 30 Table 3.2.4 Educational Attainment of the Male Household Population Percent Distribution of the De Facto Male Household Population Age Six and Over By Highest Level of Schooling Attended and Median Years of Schooling Completed, by Selected Characteristics Reproductive Health Survey: Georgia, 2010 No Education Preschool Primary(Grades 1–6) Lower Secondary (Grades 7–9) Upper Secondary (Grades 10–12) Vocational University/Postgraduate Total 3.1 2.1 9.2 10.3 34.9 11.0 29.4 100.0 19,482 10.7 Age Group 3–9 25.0 24.0 50.9 0.1 0.0 0.0 0.0 100.0 1,606 1.0 10–14 1.1 0.2 49.4 48.5 0.7 0.1 0.0 100.0 1,338 5.2 15–19 1.1 0.0 0.8 15.3 66.0 2.5 14.4 100.0 1,582 10.0 20–24 1.2 0.0 1.1 6.1 41.4 7.6 42.7 100.0 1,548 11.6 25–29 0.5 0.0 1.1 6.8 36.4 8.7 46.5 100.0 1,507 11.8 30–34 1.1 0.1 0.7 6.4 36.0 11.3 44.5 100.0 1,410 11.7 35–39 1.0 0.0 0.8 4.5 39.6 13.4 40.6 100.0 1,292 11.5 40–44 0.9 0.1 0.4 4.3 36.5 17.5 40.2 100.0 1,302 11.5 45–49 0.6 0.0 0.5 3.2 37.8 19.6 38.2 100.0 1,481 11.4 50–54 1.0 0.0 1.3 3.8 39.9 19.5 34.5 100.0 1,450 11.3 55–59 1.2 0.0 0.7 4.8 37.0 20.3 36.0 100.0 1,209 11.4 60–64 0.6 0.0 1.6 7.7 39.9 17.4 32.8 100.0 982 11.0 65–69 0.8 0.0 2.2 13.8 43.4 13.3 26.6 100.0 701 10.7 70–74 1.3 0.0 3.6 17.1 40.9 13.3 23.7 100.0 944 10.1 75–79 2.9 0.2 11.1 20.8 39.0 8.8 17.1 100.0 543 9.6 80 or more 3.0 0.3 13.9 23.9 32.0 7.5 19.4 100.0 587 9.4 Residence Urban 2.2 2.9 8.6 6.6 26.5 10.5 42.7 100.0 7,936 11.6 Rural 4.0 1.4 9.8 13.6 42.4 11.4 17.4 100.0 11,546 10.0 Region Kakheti 7.6 1.4 10.3 13.7 40.1 11.4 15.6 100.0 1,647 10.0 Tbilisi 1.9 3.0 8.5 5.4 21.6 8.9 50.7 100.0 3,638 12.3 Shida Kartli 3.4 1.3 8.2 11.3 39.3 12.0 24.5 100.0 1,271 10.3 Kvemo Kartli 4.4 1.5 13.1 15.0 35.9 8.4 21.8 100.0 1,622 9.9 Samtskhe–Javakheti 4.3 1.2 10.1 8.4 45.7 10.1 20.1 100.0 1,410 9.9 Adjara 2.8 1.9 10.6 11.8 34.4 13.4 25.1 100.0 1,134 11.1 Guria 2.1 1.0 8.0 16.8 40.2 17.7 14.2 100.0 1,534 9.9 Samegrelo 2.8 1.4 7.4 9.2 48.0 8.5 22.6 100.0 1,661 10.3 Imereti 1.7 3.1 8.1 9.8 34.7 13.5 29.0 100.0 2,362 10.6 Mtskheta–Mtianeti 2.4 2.6 9.4 13.0 34.7 15.1 22.7 100.0 1,253 10.6 Racha–Svaneti 1.7 0.9 8.6 14.9 45.6 9.2 18.9 100.0 1,950 10.0 Wealth Quintile Lowest 4.9 0.9 10.2 16.8 44.9 10.4 12.0 100.0 4,376 9.7 Second 4.1 1.5 9.7 12.8 43.0 11.5 17.4 100.0 4,691 10.1 Middle 2.7 1.9 9.6 10.2 38.8 11.9 24.9 100.0 4,318 10.5 Fourth 2.1 2.4 8.3 7.2 28.5 13.1 38.4 100.0 2,798 11.4 Highest 1.8 3.7 8.4 4.7 18.9 8.3 54.2 100.0 3,299 13.3 * Excludes one man for whom the highest level of school attendance was unknown. Characteristic Median YearsCompletedTotal No. of Cases* Highest Level of School Attended FINAL REPORT 31 Table 3.3.1 School Readiness Percentage of Children Attending First Grade of Primary School Who Attended Pre-school the Previous Year, Georgia, 2010-2011 Characteristic Percentage of children attending first grade who attended preschool in previous year [1] Number of children attending first grade of primary school Sex Male 42.5 227 Female 38.3 224 Region Kakheti 21.6 37 Tbilisi 52.3 86 Shida Kartli 25.9 27 Kvemo Kartli 41.7 36 Samtskhe-Javakheti 16.7 36 Adjara 48.0 25 Guria 34.2 41 Samegrelo 37.1 35 Imereti 43.8 73 Mtskheta-Mtianeti 53.6 28 Racha-Svaneti 22.2 27 Residence Urban 49.9 196 Rural 30.5 255 Wealth Index Quintiles Lowest 26.2 102 Second 28.3 89 Middle 39.9 101 Fourth 53.5 68 Highest 51.4 91 Total 40.4 451 [1] MICS indicator 7.2 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 32 Table 3.3.2 Primary School Entry Percentage of Children of Primary School Entry Age Entering Grade 1 (Net Intake Rate), Georgia, 2010-2011 Characteristic Percentage of children of primary school entry age entering grade 1 [1] Number of children of primary school entry age Sex Male 84.1 476 Female 81.6 440 Region Kakheti 77.5 89 Tbilisi 86.9 183 Shida Kartli 82.4 51 Kvemo Kartli 78.7 89 Samtskhe-Javakheti 82.1 67 Adjara 84.8 46 Guria 83.3 72 Samegrelo 88.9 63 Imereti 80.0 135 Mtskheta-Mtianeti 84.5 58 Racha-Svaneti 85.7 63 Residence Urban 84.5 399 Rural 81.1 517 Wealth Index Quintiles Lowest 79.2 182 Second 81.7 208 Middle 76.8 210 Fourth 86.6 135 Highest 89.4 181 Total 82.8 916 [1] MICS indicator 7.3 FINAL REPORT 33 Ta bl e 3 .3. 3 Ne t a tte nd an ce ra tio (a dj us te d) [1 ] Nu m be r o f ch ild re n Ne t a tte nd an ce ra tio (a dj us te d) [1 ] Nu m be r o f ch ild re n Ne t a tte nd an ce ra tio (a dj us te d) [1 ] Nu m be r o f ch ild re n Re gi on Ka kh eti 95 .7 11 6 90 .8 10 9 93 .3 22 5 Tb ilis i 96 .6 26 5 97 .4 23 4 97 .0 49 9 Sh ida K ar tli 96 .6 89 10 0.0 85 98 .3 17 4 Kv em o K ar tli 92 .4 14 5 94 .7 11 3 93 .4 25 8 Sa mt sk he -Ja va kh eti 92 .7 10 9 96 .7 91 94 .5 20 0 Ad jar a 95 .9 73 96 .3 80 96 .1 15 3 Gu ria 99 .0 10 3 93 .4 91 96 .4 19 4 Sa me gr elo 94 .6 11 2 95 .5 89 95 .0 20 1 Im er eti 94 .7 17 0 97 .2 14 4 95 .9 31 4 Mt sk he ta- Mt ian eti 98 .8 84 96 .4 84 97 .6 16 8 Ra ch a- Sv an eti 99 .2 11 8 96 .3 10 7 97 .8 22 5 Re sid en ce Ur ba n 96 .3 58 9 97 .2 51 1 96 .7 11 00 Ru ra l 94 .5 79 5 95 .1 71 6 94 .7 15 11 Ag e a t b eg in ni ng o f s ch oo l y ea r 6 83 .5 21 9 85 .7 20 9 84 .6 42 8 7 97 .1 22 7 97 .5 20 1 97 .3 42 8 8 99 .0 23 8 98 .1 19 1 98 .6 42 9 9 99 .4 19 9 98 .4 19 6 98 .9 39 5 10 98 .0 27 8 98 .7 22 6 98 .3 50 4 11 95 .0 22 3 98 .8 20 4 96 .8 42 7 W ea lth In de x Q ui nt ile s Lo we st 93 .1 26 7 91 .7 25 9 92 .4 52 6 Se co nd 93 .2 32 6 97 .1 30 0 95 .0 62 6 Mi dd le 98 .0 34 2 96 .6 26 1 97 .4 60 3 Fo ur th 97 .6 19 1 96 .6 18 3 97 .1 37 4 Hi gh es t 94 .8 25 8 97 .8 22 4 96 .2 48 2 To ta l 95 .4 13 84 96 .1 12 27 95 .7 26 11 P rim ar y S ch oo l A tte nd an ce P er ce nt ag e o f C hi ld re n of P rim ar y S ch oo l A ge A tte nd in g Pr im ar y o r S ec on da ry S ch oo l ( Ne t A tte nd an ce R at io ), Ge or gi a, 20 10 -2 01 1 [1 ] M IC S in di ca to r 7 .4 ; M D G in di ca to r 2 .1 Ma le Fe m ale To ta l Ch ar ac te ris tic REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 34 Ta bl e 3 .3. 4 Ne t a tte nd an ce ra tio (a dj us te d) [1 ] Pe rc en t a tte nd in g pr im ar y s ch oo l Nu m be r o f ch ild re n Ne t a tte nd an ce ra tio (a dj us te d) [1 ] Pe rc en t a tte nd in g pr im ar y s ch oo l Nu m be r o f ch ild re n Ne t a tte nd an ce ra tio (a dj us te d) [1 ] Pe rc en t a tte nd in g pr im ar y s ch oo l N um be r o f ch ild re n Re gi on Ka kh eti 72 .7 11 .6 12 1 81 .8 6.4 11 0 77 .1 9.1 23 1 Tb ilis i 86 .9 7.6 23 7 87 .2 7.4 24 3 87 .1 7.5 48 0 Sh ida K ar tli 90 .8 5.1 98 91 .3 4.9 10 3 91 .0 5.0 20 1 Kv em o K ar tli 79 .9 11 .7 15 4 81 .0 10 .2 13 7 80 .4 11 .0 29 1 Sa mt sk he -Ja va kh eti 81 .2 11 .9 10 1 83 .9 11 .0 11 8 82 .7 11 .4 21 9 Ad jar a 89 .1 5.4 92 90 .9 6.8 88 90 .0 6.1 18 0 Gu ria 90 .0 7.0 10 0 93 .5 2.2 92 91 .7 4.7 19 2 Sa me gr elo 86 .6 6.7 11 9 90 .2 2.7 11 2 88 .3 4.8 23 1 Im er eti 90 .1 7.4 16 2 91 .1 7.0 15 8 90 .6 7.2 32 0 Mt sk he ta- Mt ian eti 88 .0 2.2 92 85 .5 5.8 69 87 .0 3.7 16 1 Ra ch a- Sv an eti 88 .8 7.5 16 1 87 .7 8.7 13 8 88 .3 8.0 29 9 Re sid en ce Ur ba n 87 .9 7.4 57 6 87 .7 6.9 57 2 87 .8 7.2 11 48 Ru ra l 83 .2 8.7 86 1 87 .3 6.9 79 6 85 .2 7.8 16 57 Ag e a t b eg in ni ng o f s ch oo l y ea r 12 61 .0 36 .4 27 9 64 .1 32 .0 26 8 62 .5 34 .2 54 7 13 92 .6 3.7 27 2 93 .7 2.1 29 0 93 .2 2.8 56 2 14 92 .0 1.0 28 6 96 .9 0.5 27 5 94 .4 0.7 56 1 15 92 .2 0.4 29 9 91 .2 0.0 28 5 91 .7 0.2 58 4 16 88 .8 0.0 30 1 91 .3 0.0 25 0 89 .9 0.0 55 1 W ea lth In de x Q ui nt ile s Lo we st 76 .1 8.7 29 1 89 .5 4.2 33 0 83 .3 6.3 62 1 Se co nd 85 .6 9.9 37 3 83 .6 8.7 29 2 84 .7 9.4 66 5 Mi dd le 88 .4 5.8 32 8 84 .9 10 .1 31 3 86 .7 7.9 64 1 Fo ur th 86 .5 7.4 20 0 89 .6 6.1 18 2 88 .0 6.8 38 2 Hi gh es t 88 .3 8.4 24 5 90 .1 5.1 25 1 89 .2 6.7 49 6 To ta l 85 .4 8.1 14 37 87 .5 6.9 13 68 86 .4 7.5 28 05 P er ce nt ag e o f C hi ld re n of S ec on da ry S ch oo l A ge S ec on da ry S ch oo l A tte nd an ce A tte nd in g Se co nd ar y S ch oo l o r H ig he r ( Ad ju st ed N et A tte nd an ce R at io ), an d Pe rc en ta ge o f C hi ld re n At te nd in g Pr im ar y S ch oo l, G eo rg ia, 20 10 -2 01 1 [1 ] M IC S in di ca to r 7 .5 Ma le Fe m ale To ta l Ch ar ac te ris tic FINAL REPORT 35 Ta bl e 3 .3. 5 Ch ar ac te ris tic Pr im ar y s ch oo l co m pl et io n ra te [1 ] N um be r o f c hi ld re n of pr im ar y s ch oo l c om pl et io n ag e Tr an sit io n ra te to se co nd ar y s ch oo l [ 2] Nu m be r o f c hi ld re n wh o we re in th e las t g ra de o f p rim ar y s ch oo l t he pr ev io us ye ar Se x Ma le 89 .3 27 9 10 0.0 24 4 Fe ma le 83 .8 26 8 99 .4 20 9 Re gi on Ka kh eti 85 .7 49 10 0.0 37 Tb ilis i 84 .7 11 1 98 .8 86 Sh ida K ar tli 85 .4 41 10 0.0 34 Kv em o K ar tli 89 .1 64 10 0.0 44 Sa mt sk he -Ja va kh eti 82 .9 41 10 0.0 35 Ad jar a 85 .7 28 10 0.0 28 Gu ria 84 .4 32 10 0.0 34 Sa me gr elo 92 .1 38 10 0.0 33 Im er eti 84 .2 57 10 0.0 47 Mt sk he ta- Mt ian eti 96 .9 32 10 0.0 29 Ra ch a- Sv an eti 10 0.0 54 10 0.0 46 Re sid en ce Ur ba n 83 .7 24 0 99 .4 19 0 Ru ra l 89 .5 30 7 10 0.0 26 3 W ea lth In de x Q ui nt ile s Lo we st 80 .4 10 8 10 0.0 93 Se co nd 89 .6 12 8 10 0.0 10 2 Mi dd le 91 .5 12 5 10 0.0 11 0 Fo ur th 92 .3 80 10 0.0 62 Hi gh es t 79 .7 10 6 98 .8 86 To ta l 86 .6 54 7 99 .7 45 3 P rim ar y S ch oo l C om pl et io n an d Tr an sit io n to S ec on da ry S ch oo l P rim ar y S ch oo l C om pl et io n Ra te s a nd T ra ns iti on R at e t o Se co nd ar y S ch oo l, G eo rg ia, 20 10 -2 01 1 [1 ] M IC S in di ca to r 7 .7 [2 ] M IC S in di ca to r 7 .8 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 36 Ta bl e 3 .3. 6 Ed uc at io n Ge nd er P ar ity Ra tio o f A dj us te d Ne t A tte nd an ce R at io s o f G irl s t o Bo ys , in P rim ar y a nd S ec on da ry S ch oo l, G eo rg ia, 20 10 - 20 11 Ch ar ac te ris tic Pr im ar y s ch oo l a dj us te d ne t a tte nd an ce ra tio (N AR ), gi rls Pr im ar y s ch oo l ad ju st ed n et at te nd an ce ra tio (N AR ), bo ys Ge nd er p ar ity in de x (G PI ) f or p rim ar y sc ho ol ad ju st ed N AR [1 ] Se co nd ar y s ch oo l ad ju st ed n et at te nd an ce ra tio (N AR ), gi rls Se co nd ar y s ch oo l ad ju st ed n et at te nd an ce ra tio (N AR ), bo ys Ge nd er p ar ity in de x (G PI ) f or s ec on da ry sc ho ol ad ju st ed N AR [2 ] Re gi on Ka kh eti 90 .8 95 .7 0.9 5 81 .8 72 .7 1.1 2 Tb ilis i 97 .4 96 .6 1.0 1 87 .2 86 .9 1.0 0 Sh ida K ar tli 10 0.0 96 .6 1.0 3 91 .3 90 .8 1.0 0 Kv em o K ar tli 94 .7 92 .4 1.0 2 81 .0 79 .9 1.0 1 Sa mt sk he -Ja va kh eti 96 .7 92 .7 1.0 4 83 .9 81 .2 1.0 3 Ad jar a 96 .3 95 .9 1.0 0 90 .9 89 .1 1.0 2 Gu ria 93 .4 99 .0 0.9 4 93 .5 90 .0 1.0 4 Sa me gr elo 95 .5 94 .6 1.0 1 90 .2 86 .6 1.0 4 Im er eti 97 .2 94 .7 1.0 3 91 .1 90 .1 1.0 1 Mt sk he ta- Mt ian eti 96 .4 98 .8 0.9 8 85 .5 88 .0 0.9 7 Ra ch a- Sv an eti 96 .3 99 .2 0.9 7 87 .7 88 .8 0.9 9 Re sid en ce Ur ba n 97 .2 96 .3 1.0 1 87 .7 87 .9 1.0 0 Ru ra l 95 .1 94 .5 1.0 1 87 .3 83 .2 1.0 5 W ea lth In de x Q ui nt ile s Lo we st 91 .7 93 .1 0.9 8 89 .5 76 .1 1.1 8 Se co nd 97 .1 93 .2 1.0 4 83 .6 85 .6 0.9 8 Mi dd le 96 .6 98 .0 0.9 9 84 .9 88 .4 0.9 6 Fo ur th 96 .6 97 .6 0.9 9 89 .6 86 .5 1.0 4 Hi gh es t 97 .8 94 .8 1.0 3 90 .1 88 .3 1.0 2 To ta l 96 .1 95 .4 1.0 1 87 .5 85 .4 1.0 2 [1 ] M IC S in di ca to r 7 .9 ; M D G in di ca to r 3 .1 [2 ] M IC S in di ca to r 7 .1 0; M D G in di ca to r 3 .1 37 CHAPTER 4 FERTILITY AND PREGNANCY EXPERIENCE One objective of the survey was to assess the current levels and trends of fertility and pregnancy experienc- es and to identify factors that might influence repro- ductive behaviors. To obtain information about repro- ductive patterns, the questionnaire included a series of questions about childbearing, the use of induced abortion, desired family size and fertility preferences, and planning status of all pregnancies in the last five years. All the survey based statistics regarding preg- nancy experiences are derived from a complete life- time pregnancy history, which consists of information about all births, abortions, and fetal losses, including date of pregnancy outcome, pregnancy duration and survival status. Each woman is asked to give a detailed history of all pregnancy outcomes, from the time of the first pregnancy up to the time of the interview. This information represents an important addition to vital statistics routinely compiled at the local and state level, because it allows examination of fertility and abortion differentials by background characteris- tics and health behaviors. It also allows for more accu- rate national and regional estimates of the pregnancy events, particularly since the earlier surveys showed that official statistics understate births and abortions (Serbanescu et. al, 2001). 4.1 Fertility Levels and Trends Demographically, Georgia has much in common with the other former Soviet-bloc countries, with whom it shares a common path of transition from communism and the inheritance of a centralized state-subsidized health care system. The total fertility rate (TFR)—the average number of children that would be born alive to a woman during her childbearing years if she were to experience the age-specific fertility rates of a given year—is used as an indicator for the study of fertility levels and trends; it is comparable across countries, since it is independent of differences in the size and structure of the population. According to the official statistics, fertility has been declining steadily over the last three decades in the former Soviet Union countries with the most promi- nent declines observed between 1985 and 1995; however fertility levels, trends and the pace of de- cline differed between the Central Asia republics and the European part of the former Soviet Union (WHO, 2011a and 2011b). The decline in the TFR started sooner in Central Asia and the pace of decline was faster, resulting in the present convergence of fertil- ity rates (Figure 4.1.1). In the mid-1980s, the disparity between regions with the highest (Central Asia) and the lowest fertility (European Soviet Union) was over REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 38 3 births per woman. By the mid-1990s, this difference had decreased to 2 births per woman. By 2005 it was less than one birth per woman, with Tajikistan (the only country with fertility of 3.5 births per woman) and Latvia representing the two ex- tremes. Recently, however, the downward trend reversed in several countries. In Georgia and nine other countries (Armenia, Azerbaijan, Belarus, Esto- nia, Kazakhstan, Lithuania, Moldova, Ukraine and Uz- bekistan), the 2007–2009 TFR is higher than it was in 2004-2006. A TFR of around 2.1 births per woman is considered to be the replacement level, that is, the average number of births per woman required to keep the long run population size constant in the absence of inward or outward migration. The TFR is still below the replacement level of 2.1 births per woman in all countries outside Central Asia, excepting Azerbaijan (2.3 births per woman). Among countries of the Eu- ropean former Soviet Union, Georgia has the second highest fertility rate, surpassed only by Azerbaijan. The information obtained from the birth histories col- lected in surveys is another source for computing to- tal fertility rates. As with analyses performed in the 1999 and 2005 surveys, the pregnancy histories were used to calculate two of the most widely used meas- ures of current fertility—the total fertility rate and its component age specific fertility rates. These measures are based on information from each woman’s preg- nancy history regarding the month and year of each live birth and the maternal age at the time of delivery. The (TFR) for a period is computed by accumulating the age-specific fertility rates (ASFRs) in each 5-year age group and multiplying the sum by five (the num- ber of years in each group). The TFR for a period is thus defined as the average number of live births a woman would have during her reproductive lifetime (ages 15–44) if she experienced the currently ob- served ASFRs for that period. ASFRs are expressed as the number of births to women in a given age group per 1,000 women per year. In this survey, as in the previous rounds, the ASFR for any five-year age group was calculated by dividing the number of births to women in that age group during the period 1 to 36 months preceding the survey, by the number of wom- an-years lived by women in that age group during the same period. Age-specific fertility rates are very useful in understanding the age pattern of fertility. The TFR calculated from GERHS10 of 2.0 births per woman (95%CI=1.9–2.1) for the period 2007–2010 is the highest survey-based TFR ever reported for Geor- gia (Figure 4.1.2). The most recent period fertility rate is 25% higher than the TFR of 1.6 (95%CI=1.4–1.7) observed during 2002–2005, also calculated from the GERHS05 pregnancy histories (Serbanescu et al., 2007). As in previous comparisons, the survey-based TFR for the most recent three years was higher than the cor- responding TFR based on vital registration figures. In the previous Georgian survey rounds, the underesti- mation of births in the vital registration system was attributed mainly to two factors: 1) undercounting of births in the numerator, mainly due to delays in birth registration and 2) denominator inflation due to the use of inaccurate population projections (Serbanescu et al., 2001; Aleshina and Redmond, 2005). As shown later in this report, early registration (within the first 2 weeks after birth) was almost universal among chil- dren born in the last 5 years in Georgia, so under- registration of births is unlikely to explain differences in the TFR. The persistence of inflated denominators Trends in Total Fertility Rates in the Countries of the Former Soviet Union, 1975-2009 Figure 4.1.1 FINAL REPORT 39 is still an issue, since the census projections are done without adjustment for out-migration and overesti- mate women of childbearing age. This may result in underestimation of the fertility rates and other official population-based statistics. The ASFRs and corresponding TFR for the period 2007–2010 are shown in Table 4.1.1 and Figure 4.1.3. Traditionally, Georgian women initiate and complete childbearing at an early age, as reflected in very high age-specific fertility rates for young women. The high- est fertility levels were at ages 20-24 and 25-29, ac- counting for 36% and 29%, respectively, of the TFR. Fertility among adolescent women contributed to only 10% of the TFR. Fertility among women aged 30–34 was the third-highest ASFR, contributing 15% of the TFR. Women aged 35–39 and 40–44 made mini- mal contributions; their ASFRs accounted for only 8% and 3%, respectively, of the TFR. Thus, 26% of the TFR was due to women aged 30 or older. Using data from all Georgia reproductive health sur- veys, period fertility rates can be compared across three 3-year periods (Table 4.1.1 and Figure 4.1.4). In the most recent survey, there is an increase of 25% in the 3-year (2007–2010) TFR, compared to the rate dur- ing 2002–2005. Compared to the period 1996–1999, the TFR increased by 18%. Age-specific fertility rates increased in all but one age group, adolescent women, suggesting a gradual transition to fertility postpone- ment in Georgia. In that group the ASFR dropped from 65 during 1996–1999, to 47 during 2002–2005, and to 39 during the most recent period (2007–2010). Al- together this was a 40% decline between 1996–1999 and 2007–2010. At the same time, the ASFRs of women aged 20-24 and 25–29 increased by 26% and 25%, respectively. As a result, their contribution to the TFR increased from 59% to 65% between 1996–1999 and 2007–2010. There was also a notable change in fertility among older women: the ASFRs of women aged 30–34, 35–39, and 40–44 increased by 29%, 43%, and 57%, respectively, though within low levels, as Figure 4.1.4 shows. Their contribution to the TFR increased from 22% to 26%. Table 4.1.2 shows the number of children ever born among all women and women currently married who were interviewed in the GERHS10. Information on all past fertility reflects the accumulation of births over a woman’s entire childbearing years and is useful in looking at how average family size varies across age groups. These data, however, have a limited relation- ship to current fertility levels. Overall, 41% of all women aged 15–44 years were childless at the time of the interview, 18% reported giving birth to only one child, 29% to two children and 12% to three or more children. Although only 5% of women aged 15–19 years reported giving birth, 69% of women aged 25–29 had done so. About one in sev- en (15%) women aged 40-44 remained childless. Among currently married women, 26% have so far had only one child, 45% have had two children, and 19% have had three or more children. One in ten currently married women has never had a child. Almost one in two of the few married adolescent women (aged 15- 19) have already had a first child; 79% at ages 20–24 have done so and 92% at ages 25–29 have done so. Five percent at ages 35–44 remained childless as of the survey, suggesting fertility impairment, because voluntary childlessness is rare in Georgia and most couples tend to have at least one child. 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Three-Year Period Total Fertility Rates: Survey Estimates and Official Sources: 1999, 2005, 2010 Figure 4.1.2 Births per Woman Official Source Survey Estimate 1999 2005 2010 1.3 1.7 1.4 1.6 1.7 2.0 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 40 4.2 Fertility Differentials In examining fertility determinants it is useful to com- pare various subgroups of women. Fertility varies with social, cultural, and economic factors, which influence decision making regarding the number of children a woman or couple decides to have. Fertility among women living in urban areas, includ- ing Tbilisi, was almost 10% lower according to the TFR than among rural-dwelling women in the three-year period preceding the interview (Table 4.2). Most of the difference between the rural and urban fertility rates was due to higher ASFRs among rural residents aged 15–19, 20–24 and 25–29. Oddly, fertility at ages 30-34 was higher in urban than in rural areas. By region, fertility was the lowest in Guria (1.7 TFR, and it was the highest in Mtskheta-Mtianeti and Ra- cha-Svaneti (2.3), followed by Adjara (2.2) and Samt- skhe-Javakheti and Kakheti (2.1) (Figure 4.2.1). The highest adolescent ASFR was reported by residents of Kakheti, Kvemo-Kartli, and Racha-Svaneti (Figure 4.2.2), probably because the average age of first mar- riage and first birth is lower in these regions than in the rest of the country. Fertility differences according to education were more pronounced among younger women. Generally, peak fertility occurred at ages 25– 29 among women with the highest educational attain- ment, whereas peak fertility among women at lower educational levels occurred at ages 20–24. Fertility of the Azeri minority (2.4 TFR) was higher than that of the Georgians (2.0 TFR), the major ethnic group, due to much higher ASFRs among Azeri women aged 15– 24 (Figure 4.2.3). 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) 15-19 160 140 120 100 80 60 40 20 0 39 Births per 1,000 Women Three-Year Period (2007–2010) Age-Specific Fertility Rates Figure 4.1.3 142 115 62 30 11 20-24 25-29 30-34 35-39 40-44 Age Group 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) 15-19 140 120 100 80 60 40 20 0 Births per 1,000 Women Three-Year Period Age-Specific Fertility Rates 1999, 2005, 2010 Figure 4.1.4 20-24 25-29 30-34 35-39 40-44 Age Group GERHS10 GERHS05 GERHS99 FINAL REPORT 41 4.3 Nuptiality Because in Georgia nearly all exposure to the risk of pregnancy occurs among women who are married or in a consensual union, reproductive health behav- iors are greatly influenced by marital status. A com- parative report of surveys taken in 11 countries since 1996, covering a wide range of women’s health topics, showed that the median age at first marriage among women of reproductive age in Eastern Europe and Central Asia is between 20 and 22 years of age (CDC and ORC/Macro, 2003). Most countries of the region exhibit the highest fertility rates among currently mar- ried young adults, for two reasons: the probability of having a child is much higher among married women and couples typically have a strong desire to initiate childbearing soon after marriage (first birth typically occurs within 2 years after the marriage). Thus, it is important to know the marital distribution by age group and the changes over time in age at first union and at first birth. The proportion of currently married women in Geor- gia (58%) was comparable to that of other countries of the region (ranging from 54% in Russia to 68% in Uzbekistan) (Figure 4.3.1). In addition, a small propor- tion of women (2%) were living in consensual unions, a rate that is similar to Central Asian countries, but much lower than in other countries of the region (10% of women in Russia, 6% in Romania, and 4% in Ukraine). At the time of GERHS2010, 6.5% of women were pre- viously married (e.g., widowed, divorced, or separat- ed from a spouse or from a partner in a consensual union; see Table 4.3). More than one in three women 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) * Abkhazia: Autonomous region not under goverment control Three-Year Period Total Fertility Rates by Region Figure 4.2.1 Total Fertility Rate (Births per Woman) <2.0 2.0-2.1 2.2+* 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) * Abkhazia: Autonomous region not under goverment control Three-Year Period Age-Specific Adolescent Fertility Rates (Ages 15–19) by Region Figure 4.2.2 Adolecent ASFR (per 1,000 Women) <25 25-39 40-59 60-69 70+ * REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 42 (34%) had never been married or lived with a part- ner. The proportion of the currently married women aged 15-44 is unchanged between the 2005 and 2010 surveys (58%), but the proportion of de facto (con- sensual) marriages decreased (from 2% in 2005 to 1% in 2010). The proportion of currently married women (either le- gal or consensual marriage) was higher in rural areas than in urban areas (64% vs. 54%) and in the regions of Guria and Adjara (64%) and in Kakheti (63%) and Kvemo Kartli (63%). The proportion of previously mar- ried women was slightly higher in urban areas than in rural areas (8% vs. 5%), as was the proportion of never-married women (37% vs. 31%). Rates of marriage increase rapidly with age from 10% among 15- to 19-year-olds to 47% among women aged 20-24, and to 69% among 25- to 29-year-olds; the rate reached a maximum of 75% for women aged 40-44. The proportion of never-married women decreased sharply with age from 88% among 15- to 19-year-olds to 48% among women aged 20-24, and to 25% among 25-29, and 13% among women aged 30-34. Among women aged 35 or older, about 10% had never been married. The proportion of women married or in union was lower among women who did not complete second- ary school 45% than among women with a complete secondary or technicum education (63% and 69%, re- spectively) and those with university or postgraduate education (58%). In studying the impact of education on marital levels, it should be kept in mind that the youngest women are less likely to marry because they are less likely to marry because they are still in school 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Three-Year-Period (2007–2010) Age-Specific Fertility Rates by Ethnicity Figure 4.2.3 15-19 200 180 160 140 120 100 80 60 40 20 0 Births per 1,000 Women 20-24 25-29 30-34 35-39 40-44 Age Group Georgian Armenian Azeri 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) CZ MO RO RU UA AM AZ GE1999 GE2005 GE2010 KZ KG TM UZ 80 70 60 50 40 30 20 10 0 Percentage of Women Aged 15–44 Who Are Currently Married or in Consensual Unions* Figure 4.3.1 64 66 58 54 62 62 58 58 58 60 60 65 58 68 Eastern Europe Caucasus Central Asia * Source: CDC and ORC/Macro, 2003. Reproductive, Maternal and Child Health in Eastern Europe and Eurasia; A Comparative Report Note; CZ = Czech Rep; MD = Moldova; Ro = Romania; Ru = Russia; UA = Ukraine; AM = Armenia; AZ = Azerbaijan; GE = Georgia; KZ = Kazakhstan; KG = Kirgizia; TM = Turkmenistan; UZ = Uzbekistan FINAL REPORT 43 and the youngest age for official marital eligibility is 18 and with consent of parents – 16 years of age. Among the younger women aged 20-24 however the likelihood of being in a marital relationship, ei- ther consensual or formal, was highly correlated with education. For example in 2010, 56%-60% of young women with high school education or less (second- ary complete or incomplete) were in union, compared with 35%-49% of those with some post secondary education (Figure 4.3.2). This finding lends credence to the view that women tend to postpone marriage until after achieving their desired education goals. The trend between 1999 and 2010 shows that young women with less education are becoming less inclined to marry early. 4.4 Age at First Intercourse, Union, and Birth Age at first union and age at first sexual intercourse play an important role in determining fertility. Delays in these events decrease the number of reproductive years that a woman spends at risk of getting pregnant. They can also have a direct impact to reduce current fertility rates since births in any one year are fewer when they are deferred to some time in the future. Information on age at first sexual intercourse for all women is presented by age of the respondent at the time of interview in Table 4.4.1. The left side of the table shows the proportion of respondents within each 5-year age cohort who have ever had sexual in- tercourse (top panel), ever been in formal or consen- sual marriage (middle panel), and ever had a live birth (bottom panel), before reaching specific ages. For ex- ample, in the top panel, 30% of women now aged 25- 29 had sex before age 20. The overall median age (next to last column), for the age by which 50% of women aged 15-44 have experi- enced the event, and the median age within each age group, are also displayed for each event. By comparing the proportion of women in different age groups who experienced various events before age 20, it is pos- sible to detect whether the average age of occurrence of each event has changed over time. For example, the proportion of women who had sexual intercourse be- fore age 20 was 33% among women now aged 40-44, but otherwise it declined from a high 43% for women now aged 35-39 to 29% among 20-24-year-olds. There is very little gap between sexual exposure and entry into a union. Across age cohorts, the proportion of respondents who reported sexual experience be- fore marriage remained very low because the propor- tion of women married by age 20 is almost identical with the proportion of sexually experienced women (Figure 4.4.1). Similarly, the median age at first inter- course for each cohort was only slightly lower than the corresponding median age at first marriage. Thus, the 2010 survey confirms an earlier finding that in Geor- gia sexual abstinence before marriage is a common practice. Apparently, traditional norms are strong and have not been altered by recent changes that have influenced young adult reproductive behaviors in the industrialized world and in some of the Eastern Euro- pean former Soviet-bloc countries. The long term decline in the proportion of women who married before age 20 documents the trend away from early marriage. Since the number of women pur- suing higher education attainment has also risen, it is very likely that young Georgian women tend to delay the first union and first birth to a later age, after gain- ing qualifications and steady income. This trend is par- ticularly interesting and has potential implications for future fertility patterns and fertility control measures. Percentage Percent of Women Aged 20-24 Who Are Married, by Education Level: 1999, 2005, 2010 Figure 4.3.2 Secondary Incomplete Secondary Complete 100 80 60 40 20 0 Technicum University 1999 2005 2010 76 64 60 50 59 56 43 45 49 41 32 35 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 44 In 2010, the median ages at first union and first birth were 21.9 and 23.6 respectively (Figure 4.4.2). Geor- gian women continue to marry considerably earlier than in Western Europe, where the average age at the first marriage is about 27 years (UNECE, 2002). The median age at first intercourse is older in 2010 than in 2005 (21.8 vs. 21.3). The proportion of young adults who reported premarital sexual intercourse, although very low, almost doubled between 2005 and 2010 sur- veys (from 2.7% in 2005 to 5% in 2010) while the pro- portion with any sexual experience remained almost unchanged (66%). Urban women reported the initiation of sexual activ- ity, union, and childbearing 1.7 to 2 years later than rural women (Table 4.4.2). The highest median age for all these events was reported by women residing in Tbilisi, suggesting that the high cost of living, the pres- ence of educational opportunities, and a competitive career market in the capital may delay sexual debut, union and childbearing. Interestingly, women residing in Racha-Svaneti (mountainous area) reported simi- larly high median ages for the onset of sexual activ- ity, union and childbearing, but probably for entirely different reasons: judging from the scarcity of the population of reproductive age in the region (docu- mented in the census and in the 2010 RHS), a possi- ble explanation is that much of the male population is seeking higher education training and employment elsewhere. Differentials in median age of experienc- ing sexual activity, union, and childbearing are closely related to education. The median age of these events was 5 years older in women with university education compared to those who had not completed secondary education. 45 40 35 30 25 20 15 10 5 0 Percent Percentage of Women Aged 20-44 Who Had Sexual Debut, First Union and First Birth before Age 20 by Current Age Figure 4.4.1 20-24 25-29 30-34 35-39 40-44 Age Group First Sex First Union First Birth Median Age at First Sex, First Union and First Age Among Women Aged 15-44 Years: 1999, 2005, 2010 Figure 4.4.2 Median Age at First sex Median Age at First Union 24 23.5 23 22.5 22 21.5 21 20.5 20 Median Age at First Birth 1999 2005 2010 21.5 21.3 21.8 21.6 21.9 21.6 23.0 23.6 23.2 FINAL REPORT 45 4.5 Recent Sexual Activity Current sexual activity is an essential indicator for estimating the proportion of women who are at risk of having an unintended pregnancy and therefore in need of contraceptive services. It also has major im- plications for the selection of a contraceptive method that best suits the reproductive stage and fertility preferences of each individual. As shown in Table 4.5, about 34% of all women aged 15-44 reported that they had never had sexual intercourse. Sexual experi- ence includes the 5% of all women who were preg- nant, and the 3% reporting postpartum abstinence at the time of the interview. Nearly half, 48%, were currently active, with sexual experience in the last month, and another 10% irregularly. Among women who were married or living with a part- ner, 80% reported having had intercourse at least once within the past month, and 3% had had intercourse within the previous 3 months, plus the 13% who were pregnant or postpartum. Conversely, only 12% of pre- viously married women had had intercourse within the past 3 months. Most of them (70%) reported that their last sexual intercourse occurred over 12 months ago, perhaps while they were still married. Almost none (0.1%) of never-married women reported having had any sexual experience, yet another documenta- tion of the strong social prohibition against sex before marriage in Georgia. Almost one in three young adult women (i.e., those aged 15-24) (bottom panel) reported sexual inter- course, including the 10% who were pregnant or early postpartum. About 71% of women in the two groups aged 25 or older reported sexual experience. Of those, more than two-thirds had had intercourse within the past month. 4.6 Planning Status of the Last Pregnancy Unintended pregnancy is an important public health problem around the world, occurring in all cultures and affecting women of all ages and all socio-econom- ic and educational backgrounds. Accurate documenta- tion of reproductive intentions is important for under- standing a population’s fertility rates, fertility-related behaviors, and contraception needs. Unintended preg- nancies are more likely to be associated with elective termination of pregnancy, inadequate prenatal care, unfavorable maternal behaviors, and pregnancy or perinatal complications (Brown and Eisenberg, 1995). Unintended pregnancy has long been acknowledged as an important health, social and economic problem that creates hardships for women and their infants. Those consequences, in turn, have a broad societal impact such as the burden placed on the family, the increase in governmental health expenditures and the financial assistance for women living in poverty. Conventional measures of unintended pregnancy are designed to capture a woman’s intentions before she became pregnant (Henshaw, 1998). Thus, for each pregnancy ended since January 2005, all respondents were asked about the planning status of their preg- nancies at the time of conception. Each pregnancy was classified as either planned (i.e., wanted at the time it occurred), mistimed (i.e., occurred earlier than desired), unwanted (i.e., occurred when no children, or no more children, were desired), or unsure. Mis- Demographic Terminology for Pregnancy IntentionsFigure 4.6.1 Intended Wanted Mistimed Unintended Unwanted } } Planning Status of the Last Pregnancy Among All Women Aged 15–44 Years: 1999, 2005, 2010 Figure 4.6.2 Intended 41% Not Intended 59% Not Wanted 49% Mistimed 10% Intended 48% Not Intended 52% Not Wanted 40% Mistimed 12% Intended 63% Not Intended 36% Not Wanted 26% Mistimed 11% Georgia, 1999 Georgia, 2005 Georgia, 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 46 timed and unwanted pregnancies together constitute unintended or “unplanned” pregnancies (Westoff, 1976) (Figure 4.6.1). Reliable information on pregnancy intention, howev- er, is difficult to collect. One common problem is the underreporting of pregnancies that ended in induced abortions. Because the majority of these pregnancies are mistimed or unwanted, unplanned pregnancies will be underreported to the extent that abortions are underreported. However, abortion underreporting does not appear to be a major concern in GERHS10 (see Chapter 5). Another problem may be due to ret- rospective rationalization and ambivalence about pregnancy intention when the outcome is a live birth. Compared to self-assessments of pregnancy intention at the time of conception, retrospectively reported intentions after the child is born tend to be more positive (Miller, 1994). Thus, the data presented here represent conservative estimates of the true levels of unintended pregnancy. In GERHS10, almost two thirds (63%) of women who have been pregnant in the past 5 years reported the last pregnancy as planned; 10% reported the last preg- nancy as mistimed and 26% as unwanted, resulting in a total of 36% unplanned, i.e. not intended (Table 4.6). This compares with a level of 52% of women report- ing their last pregnancy as unplanned (not intended) in 2005 and 59% in 1999 (Figure 4.6.2). As in previous surveys, the majority of unplanned pregnancies were unwanted, but mistimed pregnancies were a larger share of all unintended pregnancies (11% of 36%) or 31% than ever before (23% in 2005 and only 17% in 1999). This shows the continuing need for attention to contraceptive services for couples wishing to space, with good timing. As Table 4.6 shows, the majority of women whose last pregnancy resulted in a live births said the birth was planned (94%). Conversely, only 3% of women whose last pregnancy ended in induced abortion re- ported that the conception was planned. A relatively high proportion (19%) of women whose last preg- nancy ended in miscarriage or stillbirth reported the conception as unwanted. This is almost 10 times the proportion found among women with live births (2%), suggesting that either unintendedness had a negative influence on pregnancy development and outcome or that some of these outcomes may have been in fact induced abortions, misreported as other fetal losses. The high rate of unwanted conceptions for pregnan- cies ending in miscarriage or stillbirth was similar to that observed in the 1999 and 2005 (Serbanescu et al., 2001, 2007). Overall, the proportion of planned pregnancies sur- passed those unplanned in all age groups except for women aged 35–44 years and those with three or more children, where the proportion fell below 50%. The proportion of pregnancies that were unplanned increased dramatically at the higher ages and family sizes (Figure 4.6.3). However among young women, aged 15-19, only 16% of pregnancies were unplanned and most of their unplanned pregnancies were mis- timed rather than unwanted. The unwanted-to-mis- timed ratio for these women was about 0.6:1, that is 5.8/9.7, and it was the same at ages 20-24. However it then reversed, and ranged from 2.1:1 to 3.8:1 to 14.9:1 across the next higher age groups. The higher the age the more conceptions were regarded as un- wanted as opposed to merely mistimed. Thus, mistimed pregnancies are rapidly replaced by unwanted pregnancies with an increase in maternal 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) 35-44 30-34 25-29 20-24 15-19 Unwanted Planning Status of the Most Recent Pregnancy by Maternal Age among Women Aged 15-44 Figure 4.6.3 Due to rounding, categories do not always add up to 100%. 0% 20% 40% 60% 80% 100% Mistimed Intended 54 39 24 8 6 4 10 12 14 10 42 51 63 78 85 FINAL REPORT 47 age, primarily because the desire for birth-spacing is replaced by the desire to terminate childbearing. As a result, virtually all unintended pregnancies were un- wanted at older ages. Women who had never given birth and women with only one child (presumably younger women) were less likely to report that their last pregnancy was unwanted than were women with two or more live births (Figure 4.6.4). Rates of unplanned pregnancy were higher among women with the lowest education level and those with the lowest wealth quintile. They were also higher among women with an Azeri or Armenian background than among Georgian women. 4.7 Future Fertility Preferences Knowledge about fertility expectations in a population is essential for helping couples to avoid unplanned pregnancies and attain their desired family size. Public health officials and health care providers need to be informed about fertility preferences so they can accu- rately help couples lower rates of unplanned pregnan- cies and induced abortion. In all surveys, the desire for more children was ex- plored by asking women if they intend to have (a/an- other) child in the future. Respondents who said that they would like to have more children were asked if they want to get pregnant right away, if they want to get pregnant within one year, within 1–2 years, or af- ter 2 years. The data presented in Table 4.7.1 and Figure 4.7.1 demonstrate that more than one in three women cur- rently married or in consensual union wanted more children; an additional 6% were unsure if they wanted to have more. Nine percent of women reported that either they or their partners were infecund. Those women were not asked about their future fertility preferences. Future fertility preferences are strongly influenced by the number of living children. For example, 70% of married women with no children wanted to have a child and almost all of them (66%/69.6%=95%) wanted to have a child within two years. Among women with one living child, 71% wanted to have an- other child in the future, including 37% who said at some time within the next two years (sum of “right away” through want in 1-2 years). This percentage decreased rapidly to 21% among women with two children, and 8% among women with three or more children. Conversely, the intention to have no more children increased rapidly with increasing number of living children (Figure 4.7.2). Among women who had had three or more children, the majority (81%) were ready to terminate childbearing. Conversely, among those with no living children, only 1% said they did not want children. The changes in fertility preferences across the three RHS surveys in Georgia are very relevant in interpret- ing the recent transition to higher fertility rates as doc- umented in 2010. As shown in Figure 4.7.3, the pro- portion of women who stated they want to have more children increased from 25% in 1999 to 35% in 2010, a 40% increase. This trend was consistent regardless of the number of living children. Particularly notable is the relatively high proportion of women with two or more children (21%) who said in 2010 they want more children, compared to only 12% in 1999. Percentage Planning Status of the Most Recent Pregnancy Children Among Married Women Aged 15–44 by Number of Living Figure 4.6.4 None One 100 80 60 40 20 0 Two Three or More Intended Mistimed Unwanted 87 3 6 81 13 6 55 11 34 48 7 45 Number of Living Children REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 48 The study of fertility patterns in Georgia has demon- strated a high concentration of childbearing at rela- tively young ages. Not surprisingly, the desire to have children was very high among young Georgian women (89% among 15–19 year-olds and 73% among 20–24 year-olds), declining to 47% at ages 25-29 and declin- ing further among women aged 30 or older (bottom panel of Table 4.7.1). About half of those wanting a(another) child wanted it within two years (Figure 4.7.4): for example 45% at ages 15-19 out of the 89% just mentioned who wanted a(another) child at some time in the future. On the other hand, among women aged 29 or younger who desired additional children, one in two wanted to wait at least two years (e.g. 34.8/72.8 at ages 20-24). Women aged 30 or older who wanted more children were more likely to want the child within the next two years and by age 40 nearly all did so. Between 1999 and 2010, there were notable changes in the timing of having a(another) child by the current age. Among the youngest women, the proportion who wanted a child within two years had declined sharply, by over a fourth, from 61% to 44% but no declines ap- peared in the proportions of women aged 30 or older wanted to have a (another) child within the next two years. These findings are consistent with the observed decline in adolescent age specific fertility rates and the increased fertility of women aged 30 years or older and may predict future increases of childbearing among older women. Future Fertility Preferences Among Married Women Aged 15–44 Figure 4.7.1 50% 9% 14% 7% 15% 6% Want No More Children Infecund Want Children Within 1 Year Want Children in 1-2 Years Want Children in 2 or More Years Undecided Percentage Intention to Have No More Children by Number of Living Children among Married Women Aged 15–44 Figure 4.7.2 Total One 100 80 60 40 20 0 Two Three or More Number of Living Children None 50 1 17 64 81 FINAL REPORT 49 A more accurate analysis concerning women who want no more children is obtained by restricting the view to only fecund women, i.e. those who can get pregnant and may be at risk of unintended pregnancy (Table 4.7.2). Further the exclusion of infecund wom- en permits a better examination of trends. (Between 1999 and 2010 there was a notable reduction in the infecund group, from 14% to 9%). The inverse rela- tionship between wanting no more children and par- ity is now more pronounced. Overall, 54% of Georgian women who could conceive reported that they did not want to have more children, but this proportion increased from 18% among those with one living child to 87% among those with three or more children (Fig- ure 4.7.5). Among women with one child, the desire to have no more children was higher for urban women than for rural women (21% vs. 15%) and it increased directly with the education level. At any parity, the intention to terminate childbearing was directly correlated with age. This pattern is similar to the one documented in the 1999 and 2005 surveys, but fewer women with two or more children in 2010 said they do not want to have a (another) child than in 1999 or 2005. The developing family planning program in Georgia needs to take account of the fertility preferences of Georgian couples, in order to provide the most ap- propriate contraceptive methods for each couple’s needs. Younger women, most of whom want to have one or more children, are more likely to need birth- spacing methods, whereas older women, the majority of whom want to stop childbearing, need longer-term or permanent methods. 4.8 Infertility Problems The 2010 survey included a module designed to as- sess current infertility levels and document existing reproductive health services for women with impaired fecundity. Infertility is often cited as a reproductive health concern in Eastern Europe given the dramat- ic declines in fertility, widespread use of abortion, Intention to Have More Children by Number of Living Children, for Married Women Aged 15–44: 1999, 2005, 2010 Figure 4.7.3 Percentage Total One 80 60 40 20 0 Two Three or More Number of Living Children None 25 27 35 63 65 70 66 64 71 12 13 21 3 4 8 1999 2005 2010 Intention to Have Children within Two Years by Age Group among Married Women Aged 15–44 1999, 2005, 2010 Figure 4.7.4 Percentage 15-19 25-29 80 60 40 20 0 30-34 40-4420-24 61 47 44 38 33 38 26 21 23 1999 2005 2010 17 15 21 7 15 2 4 77 35-39 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 50 increase in sexually transmitted infections and PID cases, and deficient health infrastructure. Although no clear documentation demonstrates that infertility rates in Georgia are increasing, anecdotic evidence leads to widespread beliefs that Georgian women seek treatment for infertility services more often than in the past, either because they may suffer from pelvic infections (as complications of abortion or childbirth) or because they experience a strong cultural pressure to conceive soon after marriage. Given that data on infertility and receipt of infertility services have impli- cations for projecting future demand for services and health care costs, the survey included a series of ques- tions about service attendance and diagnosed prob- lems. The term “impaired fecundity” in this chapter refers to a couple’s impaired ability to conceive or maintain pregnancy either because of a known medical condi- tion or because of absence of conception after at least two years of exposure to unprotected intercourse. As shown in Table 4.8.1, 10% of sexually experienced women or their partners had at some time received any infertility services and been diagnosed with im- paired fecundity. The proportion of women with the “ever” diagnosis was higher in Tbilisi than in other ur- ban or rural areas, probably because women in Tbilisi have better access to medical services that can diag- nose fecundity impairment. However among the five percent of women who reported a current fecundity impairment, Tbilisi had the smallest proportion, and rural areas had the highest proportion with problems. Current fecundity impairment increased directly with age, from 1.5% among 20- to 24-year-olds to 13% among women aged 40 or older. An exceptionally high proportion of nulliparous women reported current and ever-impaired fecundity (also known as primary impaired fecundity). Also, the proportion of women with ever-impaired fecundity was over three times higher among women who had had episodes of PID than among those without PID. Among the 10% of sexually experienced women who had attended infertility services at some time, about 25% (not shown) had pursued special medical help during the 12 months prior to the interview. Infertility problems diagnosed while seeking medical help to become pregnant are presented in Table 4.8.2. (Patients can report multiple diagnoses, so some rows add to more than 100%; other rows are less than 100% due to 75 cases with missing information). Most problems concerned ovulation difficulties, but the rest were about evenly divided at 10% to 15% each. The diagnoses varied considerably by residence and by re- gion, as well as by most other subgroups shown in the table. In conclusion for Chapter 4, the decline in fertility ob- served in Georgia in the 1990s and early 2000s was likely precipitated by the economic and social impact of the post-Communist transition. The recent fertility recovery documented in the 2010 survey coincided with the recent economic growth and political stabil- ity in the country. Currently, the adolescent fertility rate has declined but women at higher ages have an increased desire for additional children and are less likely to experience unintended pregnancies than their counterparts five years ago. Consequently, an increas- ing number of women have the number of children they want when they want them and fewer state they want no more children. As such, it is essential for the family planning efforts in Georgia to provide contra- ception advice that adequately takes into account the fertility preferences of individuals and their plans for the onset, spacing, and completion of childbearing. Percentage Intention to Have No More Children by Number of Living Children among Fecund Married Women Aged 15–44:GERHS 1999, 2005, 2010 Figure 4.7.5 Total One 100 80 60 40 20 0 Two Three or More Number of Living Children None 1 18 1 1 1819 78 68 78 91 92 87 64 63 54 FINAL REPORT 51 Table 4.1.1 Three-Year Age-Specific Fertility Rates and Total Fertility Rates for Three Time Periods Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 1999, 2005 and 2010 2007–2010 GERHS10† 2002–2005 GERHS05‡ 1996–1999 GERHS99¶  15–19 39 47 65 20–24 142 109 113 25–29 115 85 92 30–34 62 47 48 35–39 30 18 21 40–44 (11) (7) (7) Total Fertility Rate (Per Woman) 2.0 1.6 1.7 General Fertility Rate (per 1,000 Women/Year) 72 55 66 * Age at birth. † Births and exposure occurring between October 2007 and September 2010. ‡ Births and exposure occurring between March 2002 and February 2005. ¶ Births and exposure occurring between December 1996 and November 1999. ( ) Time exposed partially truncated because the sample does not include all women exposed during the reference period. Age-Specific Fertility Rate (per 1,000 Women)* Age Group (Years) Table 4.1.2 Number of Children Born Alive by Current Age of Respondents Among All Women and Among Married Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 15–19 20–24 25–29 30–34 35–39 40–44 0 41.1 94.8 59.3 31.2 19.1 15.2 15.3 1 18.4 4.6 27.3 27.5 18.0 16.8 15.4 2 28.5 0.5 12.0 33.5 45.7 44.8 42.0 3 9.3 0.1 1.3 7.3 13.4 16.9 20.6 4 or more 2.7 0.0 0.0 0.5 3.8 6.2 6.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 6,292 861 1,099 1,191 1,168 1,051 922 15–19 20–24 25–29 30–34 35–39 40–44 0 9.7 55.5 20.6 8.0 5.7 5.0 4.7 1 26.0 39.6 52.5 35.5 18.0 15.5 12.4 2 45.4 4.2 24.1 46.0 55.7 52.5 49.5 3 14.8 0.7 2.6 9.8 16.3 19.6 25.5 Age Group Number of Children Born Alive Number of Children Born Alive Married Women Total Total Age Group All Women 3 14.8 0.7 2.6 9.8 16.3 19.6 25.5 4 or more 4.1 0.0 0.1 0.7 4.3 7.5 7.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 4,098 124 610 863 948 836 717 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 52 Table 4.2 Three-Year* Age-Specific Fertility Rates and Total Fertility Rates by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 15–19 20–24 25–29 30–34 35–39 40–44 Total 39 142 115 62 30 11 2.0 Residence Urban 25 134 108 70 29 8 1.9 Rural 57 151 123 54 31 13 2.1 Region Kakheti 77 168 85 40 21 24 2.1 Tbilisi 21 127 121 73 32 13 1.9 Shida Kartli 33 133 131 59 30 0 1.9 Kvemo Kartli 64 129 118 50 22 6 1.9 Samtskhe-Javakheti 55 132 131 61 15 30 2.1 Adjara 19 166 142 58 31 26 2.2 Guria 45 138 86 53 20 0 1.7 Samegrelo 23 171 86 80 20 0 1.9 Imereti 53 135 105 62 46 0 2.0 Mtskheta-Mtianeti 39 167 148 57 26 26 2.3 Racha-Svaneti 65 198 96 67 35 5 2.3 Education Level Secondary incomplete or less 44 162 88 37 32 26 1.9 Secondary complete 48 166 118 54 25 7 2.1 Technicum 36 160 100 66 37 14 2.1 University/postgraduate 16 118 126 75 28 5 1.8 Wealth Quintile Lowest 53 148 112 47 27 12 2.0 Second 57 182 111 62 25 15 2.3 Middle 47 132 117 68 37 12 2.1 Fourth 20 118 100 61 35 3 1.7 Highest 27 133 130 69 25 11 2.0 Ethnicity Georgian 30 141 117 65 30 9 2.0 Azeri 143 184 96 18 29 0 2.4 Armenian 59 118 101 70 22 0 1.9 Other 66 144 111 60 40 73 2.5 * Births and exposure occurring between October 2007 and September 2010. † Births per 1000 women per year, by age at birth Characteristic Total Fertility Rate (Births per Woman) Age-Specific Fertility Rate (per 1,000)† FINAL REPORT 53 Table 4.3 Current Marital Status of Women Aged 15–44 Years by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Legally Married Consensual Union Previously Married Never Married Total 57.9 1.2 6.5 34.4 100.0 6,292 Residence Urban 53.6 1.3 8.0 37.1 100.0 2,975 Rural 62.8 1.2 4.8 31.2 100.0 3,317 Region Kakheti 62.8 0.6 6.5 30.1 100.0 498 Tbilisi 50.2 1.4 8.7 39.8 100.0 1,426 Shida Kartli 60.0 1.2 5.5 33.3 100.0 392 Kvemo Kartli 61.9 1.6 7.6 29.0 100.0 546 Samtskhe– Javakheti 58.5 2.6 3.9 34.9 100.0 481 Adjara 63.6 0.9 5.5 30.0 100.0 419 Guria 63.6 . 3.2 33.2 100.0 401 Samegrelo 55.5 1.2 5.0 38.3 100.0 477 Imereti 61.2 1.0 5.6 32.2 100.0 805 Mtskheta–Mtianeti 60.6 2.7 5.1 31.6 100.0 393 Racha–Svaneti 57.2 0.5 4.3 38.0 100.0 454 Age Group 15–19 10.3 0.3 0.8 88.5 100.0 861 20–24 47.1 1.6 3.2 48.2 100.0 1,099 25–29 69.5 1.5 4.2 24.8 100.0 1,191 30–34 77.0 1.0 8.8 13.1 100.0 1,168 35–39 77.4 1.8 10.8 10.1 100.0 1,051 40–44 75.0 1.4 13.2 10.5 100.0 922 Education Level Secondary incomplete or less 45.5 0.7 5.7 48.2 100.0 1,330 Secondary complete 63.5 1.5 4.9 30.0 100.0 1,568 Technicum 68.7 2.0 7.2 22.1 100.0 903 University/postgrad uate 58.0 1.2 7.6 33.2 100.0 2,491 Wealth Quintile Lowest 62.1 1.0 5.7 31.2 100.0 1,093 Second 62.8 1.1 5.3 30.8 100.0 1,385 Middle 59.7 1.9 4.7 33.7 100.0 1,413 Fourth 52.4 1.0 8.3 38.4 100.0 1,037 Highest 54.3 1.2 8.0 36.5 100.0 1,364 Ethnicity Georgian 57.0 1.3 6.3 35.3 100.0 5,488 Azeri 72.3 . 5.9 21.8 100.0 276 Armenian 57.1 1.7 5.6 35.5 100.0 364 Other 60.6 0.6 14.0 24.8 100.0 164 Employment Working 55.6 1.3 11.9 31.2 100.0 1,410 Not working 58.5 1.2 5.0 35.2 100.0 4,882 Characteristic Current Marital Status Total No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 54 Table 4.4.1 Percentage of All Women Who Had Their First Sexual Relation, First Union, And First Birth Before Selected Ages, by Current Age Reproductive Health Survey: Georgia, 2010 <15 <18 <20 <22 <25 15–19 0.5 (8.4) (11.5) NA NA 11.5 88.5 † 861 20–24 1.2 14.4 29.5 (46.1) (52.2) 52.2 47.8 † 1,099 25–29 0.9 14.6 30.0 45.5 65.9 75.3 24.7 22.4 1,191 30–34 2.0 24.4 40.9 52.3 67.7 86.9 13.1 21.1 1,166 35–39 0.7 21.6 43.2 55.9 69.6 90.1 9.9 20.6 1,051 40–44 0.7 11.2 32.8 51.4 67.5 89.5 10.5 21.6 922 Total 1.0 15.7 30.8 43.1 54.6 65.7 34.3 21.8 6,290 <15 <18 <20 <22 <25 15–19 0.4 (8.3) (11.5) NA NA 11.5 88.5 † 861 20–24 1.1 14.0 28.8 (45.6) (51.8) 51.8 48.2 † 1,099 25–29 1.2 14.7 29.6 45.6 65.8 75.2 24.8 22.6 1,191 30–34 2.2 24.9 41.0 52.7 66.7 86.9 13.1 21.4 1,168 35–39 0.9 22.1 42.9 55.6 69.3 89.9 10.1 21.0 1,051 40–44 0.6 11.0 32.4 51.2 66.7 89.5 10.5 21.9 922 Total 1.0 15.7 30.6 43.0 54.3 65.6 34.4 21.9 6,292 <15 <18 <20 <22 <25 15–19 0.2 (3.0) (5.2) NA NA 5.2 94.8 † 861 20–24 0.0 6.1 17.7 (32.3) (40.7) 40.7 59.3 † 1,099 25–29 0.1 6.9 20.2 35.1 55.8 68.8 31.2 24.1 1,191 30–34 0.2 11.8 29.0 42.2 57.4 80.9 19.1 23.4 1,168 35–39 0.2 9.5 26.3 44.3 60.9 84.8 15.2 22.8 1,051 40–44 0.2 4.7 17.3 36.7 58.4 84.7 15.3 23.4 922 Total 0.1 6.9 19.0 32.0 45.3 58.9 41.1 23.6 6,292 * Excludes 2 women who did not report the age at first intercourse. † Omitted because less than 50% in that age group had married by the age at the beginning of the interval. ( ) Age not yet attained by women aged 15-19 NA Exposure time partially truncated; not all cases have reached that age. Median Age No. of Cases Current Age Age at First Union Ever in Union Current Age Age at First Live Birth Has Had Live Birth Never Had Live Birth Never Had Intercourse Median Age No. of Cases*Current Age Age at First Sexual Intercourse Has Had Sexual Intercourse Never Had Intercourse Median Age No. of Cases FINAL REPORT 55 Table 4.4.2 Median Age at First Sexual Intercourse, First Union, and First Birth by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Characteristic Median Age at First Intercourse Median Age at First Union Median Age at First Birth Total 21.8 21.9 23.6 Residence Urban 22.6 22.8 24.6 Rural 20.9 21.1 22.6 Region Kakheti 20.7 20.7 22.2 Tbilisi 23.5 23.7 25.3 Shida Kartli 20.6 20.9 22.3 Kvemo Kartli 20.8 21.1 22.6 Samtskhe-Javakheti 20.3 20.5 21.9 Adjara 21.0 21.2 22.8 Guria 21.4 21.6 23.2 Samegrelo 22.8 23.1 24.4 Imereti 21.7 22.0 23.6 Mtskheta-Mtianeti 20.9 21.3 23.1 Racha-Svaneti 23.3 23.6 25.2 Education Level Secondary incomplete or less 19.3 19.5 20.9 Secondary complete 20.1 20.2 21.7 Technicum 21.8 21.9 23.5 University/postgraduate 24.1 24.4 25.9 No. of Cases 6,290 6,292 6,292 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 56 Table 4.5 Sexual Activity Status by Current Marital Status and Current Age Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Married Previously Married Never Married Never had intercourse 34.2 0.0 0.0 99.7 Currently pregnant 4.6 7.6 1.3 0.0 Postpartum 3.1 5.2 0.0 0.0 Within the last month 47.6 79.8 5.9 0.1 1–3 months 2.4 3.4 6.0 0.0 Over 3 months ago but within last year 1.7 1.5 11.9 0.0 One year or longer 5.8 2.0 70.2 0.0 Unknown interval 0.6 0.4 4.8 0.1 Total 100.0 100.0 100.0 100.0 No. of Cases 6,292 4,098 389 1,805 15–24 25–34 35–44 Never had intercourse 34.2 67.7 19.0 10.2 Currently pregnant 4.6 7.0 4.7 1.5 Postpartum 3.1 3.4 4.7 0.9 Within the last month 47.6 18.5 61.7 67.7 1–3 months 2.4 0.8 1.8 5.1 Over 3 months ago but within last year 1.7 1.0 2.1 2.1 One year or longer 5.8 1.1 5.7 11.5 Unknown interval 0.6 0.5 0.4 1.0 Total 100.0 100.0 100.0 100.0 No. of Cases 6,292 1,960 2,359 1,973 TotalSexual Activity Status Marital Status Sexual Activity Status Total Current Age FINAL REPORT 57 Table 4.6 Planning Status of the Last Pregnancy by Selected Characteristics Among Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Planned Mistimed Unwanted Not Sure Total No. of Cases Total 63.1 10.5 25.7 0.6 100.0 2,986 Pregnancy Outcome Current pregnancy 86.7 9.2 3.5 0.5 100.0 294 Live Birth 93.8 3.8 2.1 0.3 100.0 1,526 Induced Abortion 3.1 22.4 73.5 0.9 100.0 953 Other pregnancy outcome* 70.6 8.1 19.2 2.1 100.0 213 Residence Urban 66.5 11.4 21.6 0.5 100.0 1,354 Rural 59.7 9.6 29.9 0.8 100.0 1,632 Maternal Age at End of Pregnancy† 15–19 84.5 9.7 5.8 . 100.0 193 20–24 78.0 13.6 8.1 0.4 100.0 836 25–29 63.4 11.5 24.3 0.8 100.0 885 Characteristic Planning Status of Last Pregnancy 30–34 50.6 10.2 38.5 0.6 100.0 633 35–44 41.7 3.6 53.5 1.2 100.0 439 Number of Living Children 0 87.2 2.9 5.7 4.2 100.0 72 1 80.9 12.7 6.1 0.3 100.0 956 2 54.7 10.7 33.8 0.7 100.0 1,484 3 or more 47.8 6.6 45.1 0.5 100.0 474 Education Level Secondary complete or less 57.2 10.8 31.3 0.7 100.0 1,373 Technicum 65.5 10.6 23.8 0.2 100.0 405 University/Postgraduate 68.8 10.1 20.4 0.7 100.0 1,208 Wealth Quintile Lowest 57.8 9.5 31.4 1.3 100.0 497 Second 61.3 9.5 28.6 0.5 100.0 709 Middle 60.6 10.5 28.1 0.8 100.0 661 Fourth 69.2 11.0 19.6 0.2 100.0 475 Highest 65.4 11.6 22.5 0.5 100.0 644 Ethnicity Georgian 63.9 10.9 24.7 0.4 100.0 2,541 Azeri 54.3 6.7 36.3 2.7 100.0 166 Armenian 57.9 8.9 31.6 1.6 100.0 193 Other 68.3 11.2 20.5 0.0 100.0 86 * Includes pregnancies resulting in stillbirth, miscarriage or ectopic pregnancy. † Age of the woman at the time of pregnancy outcome, except for 294 pregnant women for whom the age is as of the interview. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 58 Table 4.7.1 1 2 Want more children 35.3 70.8 20.5 Want pregnancy right away 9.5 14.2 3.6 Want a child within a year 4.0 7.0 2.3 Want a child 1-2 years 7.3 16.1 5.1 Want a child 2 or more years 14.5 33.5 9.5 Undecided 6.3 3.9 9.0 Want no (no more) children 49.7 16.6 63.7 Subfecund, infecund couple 8.7 8.7 6.7 Total 100.0 100.0 100.0 No. of Cases 4,098 1,110 2,053 Age Group 8.1 3.2 3.6 0.4 0.8 654 4.7 100.0 29.2 100.0 281 2.7 3 or more 7.9 1.9 80.8 6.7 2.3 1.0 Preference for Children Total 0 69.6 54.7 Fertility Preferences by Number of Living Children and Age Group Among Married Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Number of Living Children* 15–19 20–24 25–29 30–34 35–39 40–44 Want more children 35.3 88.9 72.8 47.0 31.1 17.4 7.2 Want pregnancy right away 9.5 29.9 14.1 11.5 9.0 7.1 3.2 Want a child within a year 4.0 3.6 6.4 3.3 4.5 3.9 2.2 Want a child 1-2 years 7.3 11.2 17.5 8.3 7.1 3.8 1.1 Want a child 2 or more years 14.5 44.2 34.8 23.9 10.5 2.6 0.7 Undecided 6.3 3.7 8.1 9.0 8.3 4.9 1.8 Want no (no more) children 49.7 7.4 17.6 38.7 53.2 66.4 72.6 Subfecund, infecund couple 8.7 0.0 1.5 5.3 7.4 11.4 18.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 4,098 124 610 863 948 836 717 * Women who were pregnant at the time of the interview are classified as having one more child than the actual number. Age Group Preference for Children Total Table 4.7.2 Percentage of Fecund Married Women Aged 15–44 Years Saying They Want No More Children, by Number of Living Children and Selected Characteristics Reproductive Health Survey: Georgia, 2010 0 1 2 3 + Total 54.4 1.1 18.2 68.3 86.6 No. of Cases 3,728 192 1,007 1,920 609 Residence Urban 50.2 1.0 20.9 66.9 81.2 Rural 58.6 1.4 14.5 69.6 89.5 Age Group 15–24 16.1 0.0 6.2 39.1 52.9 25–34 49.4 1.7 15.0 59.2 82.6 35–44 81.2 3.2 52.6 86.9 90.7 Education Level Secondary complete or less 59.1 1.5 16.0 72.1 90.2 Number of Living Children* Characteristic Total Technicum 58.3 0.0 18.4 72.5 89.4 University/Postgraduate 47.7 1.3 20.1 62.4 77.9 * Women who were pregnant at the time of the interview are classified as having one more child than the actual number. FINAL REPORT 59 Table 4.8.1 Percentage of Sexually Experienced Women Aged 15–44 Who Reported Fecundity Impairment and Received Services by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Current Impaired Fecundity (%) Ever Had Impaired Fecundity (%) No. of Cases Total 5.1 10.5 4493 Residence Tbilisi 5.8 12.9 943 Other Urban 7.5 10.6 1105 Rural 8.9 9.3 2445 Region Kakheti 9 9 380 Tbilisi 5.8 12.9 943 Shida Kartli 8 10.1 285 Kvemo Kartli 6.4 9 420 Samtskhe-Javakheti 7.2 8.1 350 Adjara 7.4 10.4 317 Guria 10.8 7.5 290 Samegrelo 8.2 5.4 326 Imereti 10.4 13 586 Mtskheta-Mtianeti 8.3 10.2 292 Racha-Svaneti 12.3 9.7 304 Ethnicity Georgians 8 10.8 3859 Other 6.2 8.6 634 Age Group 15-19 -- 10.3 130 20-24 1.5 9.6 642 25-29 5.6 10 910 30-34 7.5 10.9 1036 35-39 10.8 10.3 946 40-44 12.9 11.7 829 Experienced PID Ever Had 11.9 21.1 1292 Never Had 6 6.1 3201 Number of Living Children 0 18.7 33.1 477 1 7.9 12.6 1286 2 6.2 5.6 2069 3 4.5 5.9 539 4 or more 4.2 2.9 122 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 60 Table 4.8.2 Percentage of Sexually Experienced Women Aged 15–44 Years with Diagnosed Infertility Problems by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Problems with ovulation (includes hormonal dysfunction), % Blocked tubes, % Endometriosis, % Semen or sperm problems (low count, poor motility, varicocele), % Inflammation, % Cyst, % Viral Infection, % Any other infertility problems, % No. of Cases Total 36.2 14.8 10.4 15.3 7.1 3.9 4.7 14.7 468 Residence Tbilisi 29.9 10.4 15.3 12.5 4.9 3.5 4.9 10.4 117 Other Urban 45.1 16.3 10.4 24.2 7.0 4.5 5.4 8.1 122 Rural 35.4 17.0 7.0 11.9 8.8 3.9 4.2 21.4 229 Region Kakheti 50.0 15.0 15.0 17.5 5.0 5.0 2.5 22.5 38 Tbilisi 29.9 10.4 15.3 12.5 4.9 3.5 4.9 10.4 117 Shida Kartli 41.2 8.8 . 5.9 2.9 8.8 5.9 29.4 31 Kvemo Kartli 33.3 13.3 4.4 13.3 8.9 4.4 8.9 31.1 37 Samtskhe-Javakheti 23.5 26.5 14.7 11.8 2.9 . 2.9 23.5 30 Adjara 43.9 26.8 2.4 19.5 19.5 2.4 . 12.2 35 Guria 36.0 20.0 20.0 16.0 . . 8.0 16.0 22 Samegrelo 55.0 10.0 . 20.0 15.0 10.0 . . 18 Imereti 34.5 16.1 9.2 21.8 4.6 2.3 5.7 8.0 78 Mtskheta-Mtianeti 40.5 10.8 29.7 2.7 10.8 8.1 10.8 8.1 32 Racha-Svaneti 26.5 23.5 14.7 14.7 8.8 5.9 . 11.8 30 Ethnicity Georgians 37.0 14.4 9.9 16.2 6.3 4.0 4.1 13.9 406 Other 30.4 17.8 13.9 8.5 13.6 3.5 9.4 19.7 62 Age Group 15-19 49.8 6.9 7.7 . . . 11.5 12.4 12 20-24 39.8 15.1 11.4 18.6 8.1 3.0 6.9 12.5 53 25-29 42.0 12.1 6.5 10.7 8.4 1.5 5.1 9.6 94 30-34 30.2 16.6 12.2 18.6 5.8 5.8 4.3 16.2 110 35-39 34.1 14.9 9.6 19.3 2.5 6.7 4.1 16.4 103 40-44 35.3 16.0 12.4 11.8 12.3 2.4 3.1 16.9 96 Number of Living Children None 34.4 15.3 6.6 28.1 4.6 2.6 6.4 12.8 166 One or more 37.1 14.5 12.3 8.7 8.4 4.6 3.8 15.5 302 61 CHAPTER 5 INDUCED ABORTION The Georgia reproductive health surveys have includ- ed extensive questions about women’s abortion expe- rience. The abortion module, which was specifically designed by CDC/DRH to capture details on unintend- ed pregnancy and pregnancy termination in Eastern Europe, explores women’s lifetime and recent abor- tion experiences. The module contains questions that prompt each respondent to report a complete life- time pregnancy history, which includes information on each pregnancy outcome (i.e., live birth, stillbirth, miscarriage or abortion) in reverse chronological or- der. For abortions, each respondent is asked the date of the pregnancy termination, pregnancy duration, and intendedness of pregnancy at the time of concep- tion (for abortions completed in the 5 years immedi- ately before the survey). For each induced abortion completed in the past 5 years, the following additional data are collected: reasons for the abortion, partner’s attitudes toward it, use of contraception at the time of conception, details related to the abortion proce- dure and care received, experience of early and late postabortion complications, and receipt of postabor- tion counseling and contraceptive methods. Abortion-related questions are asked once more in the contraceptive module to give women another opportunity to disclose their experiences. Although complete pregnancy histories are taken, respond- ents are prompted to report again on the most recent pregnancy outcomes in a month-by-month calendar of pregnancy experience and contraceptive use cover- ing of the five years immediately preceding the sur- vey. The calendar histories ask about contraception, pregnancy status, and other events during a fixed pe- riod (usually 5 years) prior to the survey. They record pregnancy and contraception events together in one place and increase the recall of reproductive health events and their timing. They also allow for internal checks of accuracy of reporting and provide interview- ers with a visual tool to help clarify inconsistencies. After consistency checks were performed, the data collected on pregnancy histories were used to calcu- late age-specific and total abortion rates, in a manner similar to age-specific and total fertility rates. It should be noted that survey-based abortion statistics are of- ten a preferred source of information about abortion in many countries in Eastern Europe (see below). The use of self-reports allows direct estimates of abortion levels among all subgroups of women (including those who seek care outside the formal health system. They provide geographic, demographic and socioeconomic characteristics of women who have had abortions (thus identifying subgroups with high unmet need for REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 62 family planning. They also simplify analysis because both the numerator and denominator of interest are readily measurable, and they allow abortion to be examined in context with other sexual and reproduc- tive health data. Survey data also have the benefit of placing abortion research within a broader context of social and reproductive health behaviors, such as fer- tility and union dynamics, demand for contraceptive methods and unmet need for family planning. 5.1 Abortion Levels and Trends Prior to 1991, a characteristic feature of the countries of Eastern Europe was their heavy reliance on abor- tion as a means of fertility control. In these countries, abortion had long been readily available, whereas ef- fective means of contraception were often lacking. Following the example of the USSR, these countries legalized abortion in the mid-1950s, well ahead of the Western European countries, and had some of the most liberal abortion policies in the world. In all but two countries, abortion was legal without restrictions as to reason during the first 12–14 weeks of gestation and up to 22–25 weeks for socio-economic and medi- cal reasons. Abortion was severely restricted only in Romania (where abortion on demand was outlawed in 1966 but liberalized again in 1989), and Albania, where the first liberal abortion law was introduced in 1995 (Rahman A et al. 1998). Currently, all countries in Central and Eastern Europe, excepting Poland, have liberal abortion laws. Because abortion has long been legal, readily available, and widely practiced in the re- gion, social stigma is typically less pronounced than in Western Europe. However, some countries have recently experienced an increased opposition to abor- tion from religious leaders, former Communists, and nationalist organizations, which may influence the so- cial acceptability of abortion. In the absence of reliable contraceptive methods, abortion rates in the Soviet Union often exceeded the fertility rates. For example, for the entire Soviet Un- ion in 1989, the abortion-to-live-birth-ratio was 1.3 to one, the abortion rate was 96 per year per1,000 women aged 15–49, and the lifetime induced abor- tion rate was 3.3 abortions per woman. Russia, Bela- rus, and Ukraine had consistently reported the highest abortion rates, whereas the rates in Central Asia were substantially lower (Goskomstat USSR, 1990). After the mid-1990s, however, the use of modern ef- fective methods of contraception increased, with a corresponding decrease in the abortion rates (Popov and David, 1999). Nevertheless, reliance on abortion as a means of fertility control is still high in some coun- tries (Figure 5.1.1). Survey-based estimates have typically shown the highest abortion rates to be in the Caucasus region where, at current age-specific rates, a woman would typically have more than 2 abortions during her life- time in Azerbaijan and Armenia. The total induced abortion rate as documented in the Georgian surveys dropped considerably over the past 10 years, from 3.7 abortions per woman in 1999 (at that time, the high- est documented rate in the world), to 3.1 abortions per woman in 2005, and to 1.6 abortions per woman in 2010. However, there are no recent reproductive or demographic health survey data in Eastern Europe so the most recent abortion level in Georgia cannot be compared to abortion rates for the same period (2007–2010) from other countries. Accurate estimates of abortion incidence are difficult to obtain in any country. The accuracy of abortion statistics depends on the presence and quality of the health information infrastructure, the methodologies employed to measure abortion rates at health facility or population levels, abortion’s legal status, and soci- etal and cultural norms (Alan Guttmacher Institute, 1999; Rossier, 2003). In countries where abortion is legal, abortion data are generally collected by gov- ernment agencies that compile statistics from health facilities and abortion providers. Official statistics on abortion are available for all the former Soviet-bloc countries, but the post-Soviet era has seen a dete- rioration of abortion reporting. Under the former re- gime, abortion data were complied by government agencies from information provided by state-run health facilities, which sometimes misreported un- favorable health statistics. The post-Soviet economic transition led to other data problems, such as those caused by the failure to record or report abortions in underfunded state-run health facilities, as well as the expansion of the private health sector whose activi- ties are usually not included in official statistics, and, to a smaller extent, the persistence of abortions per- formed outside clinical settings (Serbanescu and Mor- ris 2003). The use of inflated population projections to calculate abortion rates was another factor that may have played a role in lowering abortion rates, particu- larly in the Caucasus region. The RHS surveys in Eastern Europe provide a quick and affordable way to obtain more complete data on abortion than those provided by the routine health information systems. Despite a certain degree of sam- pling error and some inherent limitations (omissions, misclassification of abortions that are obtained out- side the legal system, and poor recall of events that occurred long before the survey date), survey-based measurements in Eastern Europe generally give a bet- ter estimate of abortion rates and ratios than the of- FINAL REPORT 63 ficial statistics. Figure 5.1.2 compares abortion statis- tics from the surveys and from government sources in terms of the general abortion rate (GAR), a summary measure that tells the annual number of abortions per 1,000 women of reproductive age. With the ex- ception of Moldova, where there is good agreement between the abortion levels from both data sources, in all other countries the survey estimates exceed gov- ernment rates by at least 20%. In the Caucasus, the survey estimates are several times higher than official rates—which suggests a breakdown in the govern- ment system for collecting abortion statistics. Overall, it appears that government statistics underestimate abortion levels in most of the surveyed countries. The survey data also allow for calculation of the total abortion rate (TIAR), which tells the number of abor- tions a woman would have in her lifetime under the current age specific abortion rates (ASIARs). The of- ficial statistics do not routinely calculate total abortion rates. Based on the most recent ASIARs for abortions performed in governmental facilities, as reported by the Georgian Ministry of Labor, Health, and Social Affairs (MoLHSA), the estimated TIAR for the period 2007–2010 was 0.9 abortions per woman, which is 44% lower than the rate documented in the survey but an improvement from the underreporting docu- mented in previous surveys (over 80% underreporting of the TIAR in 1999 and 2005). As shown in Figure 5.1.3, the abortion trends in Geor- gia are very different based the official statistics when compared to the survey reports and do not inform health policies about the real demand for contracep- tive methods and unmet need for family planning. Reported vital statistics data indicate a steep decline 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) MD RO RU UA AM AZ GE 1999 GE 2005 GE 2010 KZ KG TM UZ 4 3 2 1 0 Total Abortion Rates (per Woman): Recent Survey Estimates in Eastern Europe and Eurasia Figure 5.1.1 1.3 2.2 2.3 1.6 2.6 3.2 3.1 1.6 3.7 1.4 1.5 0.8 Eastern Europe Caucasus Central Asia * Source: CDC and ORC/Macro, 2003. Reproductive, Maternal and Child Health in Eastern Europe and Eurasia; A Comparative Report Note; CZ = Czech Rep; MD = Moldova; Ro = Romania; Ru = Russia; UA = Ukraine; AM = Armenia; AZ = Azerbaijan; GE = Georgia; KZ = Kazakhstan; KG = Kirgizia; TM = Turkmenistan; UZ = Uzbekistan 0.6 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Georgia 1999 General Abortion Rates (per 1,000 Women) in Eastern Europe: Survey Estimates and Governmental Sources Figure 5.1.2 125 Survey Estimate Official Source Source: CDC and ORC Macro, 2003. Reproductive, Maternal and Child Health in Eastern Europe and Eurasia A Comparative Report ; Serbanescu et al., 2007. Georgia 2005 Georgia 2010 Azerbaijan 2001 Armenia 2000 Romania 1999 Ukraine 1999 Moldova 1997 18 104 15 31 56 10 116 17 81 62 74 42 55 43 43 R a t e p e r 1 .0 0 0 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 64 in the total abortion rate since the break up of the former Soviet Union (from 1.8 abortions per woman in 1989, to 0.6 abortion per woman in 1997–1999, to 0.4 abortion per woman in 2002–2004) and a recent increase to almost one abortion per woman for the period 2008–2010. This trend, however, is not paral- leled in the RHS data. Previous RHS surveys showed a steep increase in the TIAR after 1990, with a peak of 3.7 abortions per woman in 1996–1999. The abor- tion rate declined gradually to a level of 3.1 abortions per woman (95%CI= 2.9–3.4 abortions per woman) in 2002–2005. Between the 2005 and 2010 surveys, the abortion rate dropped significantly to 1.6 abortions per woman (95%CI= 1.5–1.8 abortions per woman), a 48% decline from 3.1 (Table 5.1 and Figure 5.1.4.) The abortion decline documented in the surveys is consistent with the increase in fertility levels, fertil- ity desires and use of modern contraceptive meth- ods (Figure 5.1.4). However, to verify that potential changes in women’s willingness to disclose abortion experiences did not affect significantly the downward abortion trend, a check of survey-based abortion lev- els was performed as follows. Without the existence of reliable national data, there are few options for estimating the level of completeness of abortion re- porting in population-based surveys. But consistency of reporting on abortion may be examined by com- paring abortion rates for the same cohorts of women in the same period of time from successive surveys. The 5-year, age-specific abortion rates of women aged 15–39 in the period 6–8 years before the most recent cycle of the survey (GERHS10) was found to be within confidence intervals of the corresponding abortion rates for the same calendar period (2002–2005) using data from the GERHS05 survey (Figure 5.1.5). Table 5.1 also presents age specific abortion rates for women aged 15–44 years for three time periods. To avoid age truncation, the most recent 3-year period before each survey is used. The rates were calculated by using the month and year of each abortion and the age of the woman at the time of the pregnancy’s termination. The survey data were also used to calcu- late the general abortion rate (the number of abor- tions per year per 1,000 women aged 15–44), aver- aged over the 3 years preceding each survey. The rate dropped from 125 in 1996–1999 to 104 in 2002–2005 and 56 in 2007–2010. (The comparative figures in the official statistics were 18, 15, and 31 abortions per 1,000 women, respec- tively (see Figure 5.1.2 above) The survey-based estimate of the abortion-to-live– birth ratio changed from to 2.1 induced abortions for each live birth (2.1:1) in GERHS99, to 1.5:1 in GERHS05 to 0.8:1 in GERHS10. Thus, birth experience surpassed abortion experience in 2010 for the first time since survey-based reports were collected. This was mainly achieved by a combination of increases in fertility and declines in abortion in the age-groups 20–24, 25–29, and 30–34, which contribute the most to both total fertility and total abortion rates (Figure 5.1.6). Unlike fertility, which is most concentrated at ages 20–24 years, abortion rates are most concentrated at ages 25–29 years (102 induced abortions per year per 1,000 women) and 30–34 years (83 per 1,000), the two age groups that account for more than half (56%) of the TIAR. The third highest age specific abor- tion rate (57 per 1000), contributing to 25% of the TIAR, occurred among women aged 35–39 years. The ASIARs were significantly higher than ASFRs only Trends in the Period Total Induced Abortion Rate Survey Estimates and Governmental Sources Georgia 1999, 2005, 2010 Figure 5.1.3 Induced Abortions per Woman Official Source Survey Estimate 1999 2005 2010 0.9 1989 3.1 3.7 0.6 1.8 0.4 1.6 FINAL REPORT 65 Changes in Fertility, Abortion Rate and Contraceptive Prevalence between 1999 and 2010 Figure 5.1.4 Event per Woman 1997-1999 1.7 3.7 4 3 2 1 0 2002-2005 3.1 1.6 2007-2010 1.6 2.0 54 52 50 48 46 44 42 40 38 41 47 53 Percentage of Married Woman TFR TIAR CPR Total Fertility Rate and Total Abortion Rate for Women Ages 15–39 in the Period 2002–2005 Using GERHS05 and GERHS10 Figure 5.1.5 Event per Woman TFR 4 3 2 1 0 TIAR GERHS05 GERHS10 Three-Year-Period (2007–2010) Age-Specific Fertility and Abortion Rates per 1,000 Women Aged 15–44 Figure 5.1.6 15-19 25-29 30-34 40-4420-24 35-39 39 10 142 56 115 102 62 83 57 30 11 21 Births per 1.000 Women/Year Abortions per 1.000 Women/Year REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 66 among women aged 30 or older, suggesting that most Georgian women continue to achieve their desired family size before age 30 after which, in the event of having unplanned pregnancies they are more likely to end them in induced abortions (Figure 5.1.7). Strong age-specific distribution patterns were also documented in previous surveys (Table 5.1 and Fig- ure 5.1.7). Very large declines in the rates occurred at ages 20 through 39, with a modest change in the six year period between the first and second surveys, and then an especially sharp one in the five year period between the second and third surveys. Overall the abortion rate at ages 20-24 fell by a full 65%. In the next higher age groups, for 25-29, 30-34, and 35-39, the declines were 47%, 46%, and 53%. The figure shows rates; in terms of absolute numbers the savings in abortions were greatest between ages 20 and 29 since the numbers of married women in the base are largest there. 5.2 Induced Abortion Differentials Table 5.2.1 shows total and age-specific abortion rates among all women by the women’s background charac- teristics. Women in rural areas continue to have much higher age-specific abortion rates than urban women (Figure 5.2.1). Abortion rates were higher among rural women than urban women at all ages, but the great- est difference (2.4 times higher) was observed among women aged 25–29 years, the group that accounts for the largest contribution to the TIAR. Total abortion rates were highest among residents of Kvemo Kartli (2.4 abortions per woman), and among residents of Shida Kartli, Samegrelo, Guria, Mtskheta- Mtianeti, and Kakheti (1.9–2.2 abortions per woman) (Figure 5.2.2). The lowest TIARs were documented in Tbilisi, Racha-Svaneti, and Adjara (1.1–1.2 abortions per woman). The TIAR was highest for women with less than complete secondary education; on average, they underwent 1.7 abortions more than women with 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) 15-19 200 180 160 140 120 100 80 60 40 20 0 Abortions per 1.000 Women Three-Year-Period Age-Specific Abortion Rates for Three Time Periods among All Women Aged 15–44 Georgia 1999, 2005, 2010 Figure 5.1.7 20-24 25-29 30-34 35-39 40-44 Age Group 2007-2010 2002-2005 1996-1999 Three-Year-Period (2007–2010) Age-Specific Abortion Rates (per 1,000 Women Aged 15–44) by Residence Figure 5.2.1 Urban Rural 15-19 25-29 30-34 40-4420-24 35-39 6 14 42 71 150 62 74 93 41 74 26 16 Age Group FINAL REPORT 67 a university education (2.7 vs. 1.0 abortion per wom- an). The TIAR was also inversely correlated with the wealth quintile of the households, declining from around two abortions per woman in households in the lowest wealth quintiles to about one abortion per woman the highest quintile. Abortion rates were highest among women of the Azeri ethnic group (3.3 abortions per woman) and lowest among Georgian women, at 1.5 abortions per woman). Azeri women consistently re- ported the highest abortion rates at any age, but the largest differences with Georgian women were among 25–29 year-olds and 30–39 year-olds, the age groups that contribute to over 75% of the TIAR (Figure 5.2.3). Abortions are somewhat concentrated among a subset of women, since only 37% of all women re- port any lifetime experience with the method (Table 5.2.2). That figure reflects the near absence of abor- tions among the unmarried or those recently married, many of whom are seeking their first child. Among those with experience, women cluster toward a small- er number of abortions: 55% report only one or two; 70% report one to three Nevertheless, at the other ex- treme, 11% report having had seven to ten or more. Abortion experience is greater in rural than in urban areas, but is less among the less educated. The bot- tom three quintiles report more experience than the upper two; this may be related to rural residence and older age. The Azeri ethnic group is notable for a high- er experience with lifetime experience and more with numerous abortions than the other groups. Most abortions (59%) were performed at 7-9 weeks of gestation (Table 5.2.3). The decision to perform abor- tion after 10 weeks of gestation correlated with three or more children. In the group of respondents with no children only 5% had abortions later, while it reached 16% for women with three children and 29% for wom- en with four or more children. 5.3 Abortion Services As part of the former USSR, Georgia was subject to lib- eral abortion legislation issued by the Soviet Supreme Council in November 1955. The law remained in force for many years, essentially unchanged except for sev- eral minor additions and modifications. Briefly, these changes allowed for abortion by electric vacuum aspi- ration; permitted abortions in the first seven weeks of pregnancy (mini-abortions) to be performed in ambu- latory clinics; authorized abortion on medical and so- cial grounds up to 28 weeks of gestation; and legalized “commercial” abortions in private clinics and for-fee sections of state hospitals (USSR MOH, Order No. 234 of March 1982, order No. 757 of June 1987 and Order No.1342 of December 1987). These provisions constituted the foundation for legal abortion in Georgia until 1997, when the new health care law included detailed provisions concerning abortion and contraception practices (Government of Georgia, 1997). Under the current law, abortion is permitted without restrictions as to reason during the first 12 weeks and for social or medical reasons be- yond 12 weeks (IPPF, 2007). A written consent of the woman and pre-abortion counseling are necessary before the abortion. Parental consent is required for adolescent girls under 16 years of age. Induced abor- tion can be performed only by gynecologists, using ei- ther vacuum aspiration or sharp curettage; abortion procedures are permitted only in medical facilities that have been state-certified for performing abor- 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) <45 45-54 55-69 70-79 80+ * Abkhazia: Autonomous region not under goverment control Three-Year-Period (2002–2005) Total Induced Abortion Rate by Region Figure 5.2.2 Total Induced Abortion Rate (Abortions per Woman) 2.3+ 1.9-2.2 1.5-1.8 <1.5 * REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 68 tion. Abortion patients are typically released the same day of the procedure if they do not have postabor- tion complications. Outpatient medical facilities (e.g., women’s consultation clinics and private clinics) can perform induced abortion only by vacuum aspiration. The cost of abortion procedures is not covered by health insurance, but it is relatively low. Unofficial payments or payments for “extra” services, such as anesthesia, can increase the cost by a considerable amount. The standard abortion module in the RHS surveys in- cludes information on respondents’ last four abortions performed during the five years prior to the survey. For each abortion questions are asked about the rea- son for the abortion; the place where the procedure was performed; abortion registration and payments; use of local or general anesthesia and antibiotic pre- scriptions; number of nights, if any, spent in the hos- pital after the procedure; any early or late complica- tions after the abortion; and the type of counseling received before and/or after the abortion. Data are collected starting with the most recent procedure, in an attempt to minimize recall biases. Of all abortions reported by survey respondents in the five years prior to 2010, the majority (71%) were mini-abortions (Table 5.3.1 and Figure 5.3.1). The high proportion of mini-abortions contrasts with the level documented in 1999 and 2005, when only 40% and 56% of all abortions, respectively, were reported as mini-abortions. Mini-abortions were more prevalent among respondents residing in Tbilisi, Shida-Kartli and Adjara (over 80% of all abortions) (Figure 5.3.2). Urban residents (81%) were more likely to have had 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Three-Year-Period (2007–2010) Age-Specific Abortion Rates by Ethnicity Figure 5.2.3 15-19 250 200 150 100 50 0 Abortions per 1,000 Women 20-24 25-29 30-34 35-39 40-44 Age Group Azeri Armenian Georgian 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) 1995-1999 2000-2005 2005-2010 Percentage Distribution of Abortions by Type of Procedure (abortions in 5 years prior to survey) Figure 5.3.1 0 20 40 60 80 100 61 44 29 40 56 71 Induced Abortion Mini-Abortion FINAL REPORT 69 mini-abortions than rural residents (63%). The pro- portion of abortions classified as mini-abortions de- creased somewhat with woman’s age and increased directly with education and higher wealth quintiles. As shown in Table 5.3.2 and Figure 5.3.3, most induced abortions occurring in 2005 or later were performed in gynecological wards (56%); 42% were performed in ambulatory clinics, such as women’s consultation clin- ics (WCCs); and 2% were performed outside medical facilities. Abortions performed in ambulatory clinics were more prevalent in Tbilisi and other urban areas (70% and 51%) than in rural areas (30%). Compared to previous surveys, the place of most abortion proce- dures in urban areas gradually shifted from hospitals to ambulatory settings—the proportion of abortions performed in ambulatory clinics increased from 38% in 1999, to 42% in 2005, to 60% in 2010—but re- mained predominantly hospital-based in rural areas (data not shown). The proportion of abortions per- formed in ambulatory clinics increased with education and higher wealth quintiles. Almost 2% of pregnancy terminations were reported to have taken place outside the health system. Be- cause abortions performed outside medical facilities (self-induced, performed by lay persons, or performed by doctors outside the health system) are illegal, it is likely that women were reluctant to admit these outcomes, in spite of the interviewer’s assurance of anonymity. Therefore, this figure is probably an un- derestimate of the proportion of abortions performed outside the health facilities. As Table 5.3.3 shows, there were 2054 abortions that occurred to the respondents between January 2005 and the date of the interview, approximately a five year period. (Some respondents reported more than one abortion.) For only 548 (26.4%) of the pregnan- cies did the women report using any contraceptive method prior to the pregnancy (at the time of concep- tion). (Again, some respondents reported more than one pregnancy with contraceptive use.) So about one out of four abortions (26%) was report- edly due to contraceptive method failure, most of them (76%) due to failure while using a traditional method (either withdrawal or periodic abstinence). There was little variation in reporting contraceptive method failure leading to an abortion, except for lower rates among residents of Samegrelo and Shida Kartli, and a high rate for Samtskhe-Javakheti. Among women of other ethnic groups than Georgian, mod- ern methods played a small role. However, failure of traditional methods was more likely to be reported by women in rural areas, older women, women with the lowest wealth quintile, and women of Azeri or Arme- nian ethnic background. In Georgia, almost all abortions are performed for a fee, which may vary from one facility to another. At the time of the survey, mean charges for an abortion procedure were almost 48 Georgian Lari or GEL (about US$29.00), which represents an increase of 65% com- pared to the average cost in 2005 (not shown). The amount paid for an abortion ranged from no pay- ment to over 100 GEL. Only 2.3% of abortions were performed at no charge; 29% of abortion payments were 34 GEL or less, 23% were between 35–49 GEL, and 45% were 50 GEL or more, including 6% that were more than 100 GEL (Table 5.3.4 and Figure 5.3.4). Average abortion payments were lower among rural women than urban women and increased directly to- * Abkhazia: Autonomous region not under goverment control Percentage of Mini-Abortions Among All Abortions in the Past 5 Years by Region Figure 5.3.2 % of Mini-Abortions 80+ 65-79 55-64 <55 * REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 70 ward the higher wealth quintiles of the households. On average, the cost of an induced abortion was 10 GEL more than of a mini-abortion; similarly, abortions performed at 10 or more weeks of pregnancy were more costly than abortions performed in the first 9 weeks of pregnancy (64.8 GEL vs. 45.8 GEL). The aver- age abortion payment did not vary by the two types of medical facilities. Women who decide to end their pregnancies in abor- tion and do not adopt an effective contraceptive method afterwards are likely to be at high risk for another unintended pregnancy during the immedi- ate post-abortion period. Family planning counseling around the time of the abortion procedure is mandat- ed as part of the Georgian health care law. The Ministry of Labor, Health and Social Affairs in- troduced in 2000 a decree regarding family planning counseling after abortions performed in WCC (Wom- en’s Consultation Clinics) (MoLHSA, Decree num- ber 136, 2000). In paragraph 11, the decree states that every woman who has terminated a pregnancy through vacuum aspiration should be given informa- tion on modern methods of contraception (attending physician required to obtain the patient’s signature to certify counseling was provided) and a method should be selected after counseling. Training on family plan- ning counseling and service provision is currently in- cluded in the post-graduate and licensing programs for Ob/Gyns and reproductiologists. Despite legal regulations along with significant amounts of resourc- es and technical efforts invested in family planning counseling by the donors, the receipt of family plan- % of Induced Abortions Location of Abortions Performed in the Last 5 Years, Georgia, 1999, 2005, and 2010 Figure 5.3.3 Hospital Ambulatory Clinic 100 80 60 40 20 0 Outside a Medical Facility 1999 2005 2010 70 57 56 27 42 42 3 0.8 2 Cost of a Procedure for Pregnancy Termination Among Abortions Performed in the Last 5 Years Georgia, 1999, 2005, and 2010 Figure 5.3.4 None <30 90 80 70 60 50 40 30 20 10 0 Don’t Recall 2.7 Percent of Abortions Cost of Abortion (in Lari) >30 1.6 2.3 77.4 52.5 12.6 12.3 45.3 83.9 6.0 0.6 1.3 1999 2005 2010 FINAL REPORT 71 ning services around the time of having an abortion remains quite limited. Similar to previous surveys, GERHS10 asked all re- spondents who had an abortion in the last five years if they 1) received any family planning advice either be- fore or after the abortion procedure; 2) received any contraceptive method or a prescription for any meth- od; and 3) were referred to a family planning facility following the procedure. As Table 5.3.5 indicates, only one in three (33%) respondents with a history of at least one abortion on request in the last five years reported receiving contraceptive counseling (10% be- fore and 13% after, the rest at both times.) Contraceptive counseling was the highest in Imereti (46%) and the lowest in Samtskhe-Javakheti (14%). It increased slightly with education and wealth quintile and was higher among Georgian women than among women of other ethnic backgrounds. Unfortunately, receipt of contraception counseling did not vary signif- icantly by the abortion order (Figure 5.3.5). Although the highest exposure to counseling was reported by women with four or five abortions, , women with six or more repeat abortions had the same likelihood of receiving contraceptive information, supplies, or a prescription for supplies as did women with only one abortion in the last 5 years. Only 6.6% of all women with a history of abortion in the past five years (20% of women who received coun- seling) received a contraceptive method to prevent future unintended pregnancies. An additional 7.4% of women received a prescription for contraceptive supplies (22% of all women counseled). Both receipt of contraceptive supplies and receipt of prescription were low across all subgroups, excepting among wom- en in Imereti (16% and 10%, respectively). Receipt of contraceptive information in 2010 was more than twice the level documented in the 1999 survey (33% vs. 15%); more importantly, receipt of either a con- traceptive method or prescription for a method had almost tripled, from 5% to 14% (Figure 5.3.6). These findings demonstrate a great need to improve and expand availability of counseling, referrals, and provision of contraceptives at the time of the abortion procedure. This will require more rigorous oversight of adherence to current regulations concerning provi- sion of family planning advice and services post-abor- tion. Additionally, systems must be in place to support full integration of family planning services at facilities where abortion is provided. Client education may also facilitate changes in their perceptions of and expec- tations for abortion services, which may increase de- mand for counseling, referrals, and provision of con- traceptive methods. One issue concerns the use of ultrasound during the pregnancy, either to measure the length of gestation or to determine the sex of the fetus. Table 5.3.6 is restricted to women who terminated their pregnan- cies by abortion; of them, about half (51.8%) had ul- trasound to measure gestation duration. Only 3% re- ported having had it to know the sex of the fetus. The later increased by age to 5% but sharply by number of living children to a high 20% at four or more. It was also quite high, at 16.8%, where the gestational age was 10 or more weeks long. Contrarily, t was quite low, at 1.1% among women having a mini-abortion. Receipt of Contraceptive Information, Methods, or Prescription at the Time of an Abortion in the Last 5 Years by Abortion Order Figure 5.3.5 Percent First 31 14 50 40 30 20 10 0 Second Third Information Method or Prescription Fourth or Fifth Sixth or higher 34 17 11 38 17 33 11 31 Abortion Order REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 72 5.4 Abortion Complications Although standard surgical abortion is remarkably safe when compared to childbirth or other surgical procedures, it has an inherent risk of complications (Cates W. Jr., 1982). Legally induced abortions are associated with a certain risk of postoperative com- plications, whose incidence and severity are strongly correlated with age of gestation, parity, woman’s age, surgical procedure, operator’s skill, type of anesthe- sia, and preexisting pathology (Tietze and Henshaw, 1986). Abortions performed at 7 to 9 weeks of gesta- tion have significantly fewer complications than those performed between 10 and 14 weeks. Similarly, abor- tions performed by vacuum aspiration have fewer complications than the classic D&C procedure. Addi- tionally, legality alone does not make the procedure safe. Shortage of equipment, crowded facilities, poor hygienic conditions, and inadequate standards of care may increase the risk of post-abortion complications. These factors may turn women seeking pregnancy termination away from hospitals or may increase the waiting time between an initial consultation and ad- mission to a designated facility. When delays in hos- pital admission would place the gestation age beyond the 12-week legal limit, women may seek an illegal, risky abortion outside a licensed facility. Unsafe abor- tion carries a high risk of mortality and morbidity. Reproductive health surveys conducted in the region asked all respondents with abortions in the 5 years preceding a survey about the occurrence of medical complications after pregnancy termination, but can- not document abortion-related mortality. Survey esti- mates of postabortion complications are usually based on symptoms or conditions reported by respondents and therefore may be less accurate than hospital based statistics. As shown in Figure 5.4.1, the rates of early complications (within 6 months) and late com- plications (6 months or later) ranged from 5%–16% and 1%–6%, respectively. These rates are high relative to those reported for first-trimester abortions in the United States (0.3%) (Finer and Zolna, 2011). The 2010 survey in Georgia showed that 10% of all abortions performed since 2005 were followed by im- mediate complications (6.4%) or late sequelae (3.6%) (Table 5.4.1). Reports of early and late complications did not vary significantly by respondents’ background characteristics. However the prevalence of early com- plications increased by nearly a third (to 8.2%) after 10 weeks of gestation and by nearly half (to 9.5%) after D&C procedures than after mini-abortions. The prevalence of postabortion complications is higher in 2010 than it was in 2005; 10% of pregnancy terminations were followed by early or late complica- tions in 2005–2010 compared to 6.3% in 2000-2004 (Figure 5.4.1). The elevation in abortion morbidity is registered in all categories, as being above 6.3% in all cases (Table 5.4.1). One of the risk factors that is strongly associated with morbidity from legal abortion is gestational age at the time of the abortion. Between 2005 and 2010, the proportion of late abortions (after 12 weeks of gesta- tion) among all abortions increased from 1% to more than 11%. That unfortunate result appears to over- ride other influences. For example there were chang- es in clinical practice, with 41.5% of all abortions fol- lowed with antibiotic treatment in 2010 compared to just 32% in 2005. Despite that the number of compli- cations increased. The use of anesthesia very slightly decreased from 58.0% to 56.6%. The percentage of Receipt of Contraceptive Counseling at the Time of an Abortion in the Last 5 Years Georgia, 1999, 2005, and 2010 Figure 5.3.6 Percent Georgia 1999 15 5 35 30 25 20 15 10 5 0 Georgia 2005 Georgia 2010 Received Information Received a Method or Prescription 22 6 14 33 FINAL REPORT 73 abortions that were hospitalized for postabortion complications decreased (from 12% in 2005 to 0.6% in 2010), due partly to the increase in mini-abortions. Fifty-nine percent of complicated abortions had pro- longed pelvic pain; other complaints included fever (37%), severe bleeding (34%), infectious vaginal dis- charge (22%), and perforation (1.7%) (Table 5.4.2). With the exception of uterine perforation and severe bleeding, it is difficult to assess how serious the other early complications were. As mentioned, only 0.6% of immediate complications required one or more nights of hospitalization. 5.5 Reasons for Abortion The life circumstances within which women decide to have an abortion bear directly on the issue of access to abortion services; they also provide evidence of how barriers to these services may affect women’s lives. A comparative report of surveys taken since 1996, cov- ering a wide range of women’s health topics, showed that women’s reported reasons for ending pregnan- cies have been consistent in the region (Figure 5.5.1). Most of the abortions in the five years preceding the surveys occurred because a woman wanted no more children or because the family socio-economic cir- cumstances could not support another child. Overall, between 66% and 95% of abortions were for these two reasons (CDC and Macro, 2003). The 2010 survey in Georgia showed that most of the abortions in the five years preceding the survey were obtained because the woman wanted no more chil- dren (51%) (Table 5.5) or because the family socio- economic circumstances could not support another child (20%), due to low income, unemployment, fear of losing a job, or crowded living conditions. Nearly one in five abortions (18%) was obtained because the woman wanted to space her childbearing. Another 8% were obtained for health-related reasons: 5% for maternal health reasons (i.e., pregnancy was threat- ening the woman’s physical or mental health), and about 3% because of fetal defects or potential risks for the baby. Next, 1.5% reflected partner-related rea- sons (e.g., the partner objected to the pregnancy). Fi- nally, note that 1.4% of women stated they obtained abortions because of the sex of the fetus, which was known prior to the decision to terminate the pregnan- cy (data not shown). In terms of trends, compared to 1999, women in 2010 were less likely to have abor- tions for limiting fertility and more likely to have them for spacing and for health reasons. The use of abortion for limiting childbearing was men- tioned more often by rural women (who already have a higher mean number of living children than urban women), and by women over age 34 (62%), who also have more children. A woman’s desire for no (more) children as a reason for abortion was strongly corre- lated with pregnancy order, from 18% among women pregnant for the second time to 40% among women with two previous pregnancies and 62% among those with four or more previous pregnancies. Use of abor- tion for spacing the next birth was more common among non-Tbilisi urban residents, women aged 15- 24 years, women belonging to the second wealth quintile, and those with one previous pregnancy. So- cioeconomic reasons were reported more often in Tbilisi and in the lowest wealth quintile. Thus, women seeking abortions are mostly motivated by their family size and by socio-economic impacts on the family members, especially their children. The 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Prevalence of Early and Late Post-Abortion Complications: Eastern Europe and Georgia Surveys Figure 5.4.1 Note: MO = Moldova; RO = Romania: RU = Russia; AZ = Azerbaijan; GE = Georgia MO RO RU UA AZ GE 1999 GE 2005 GE 2010 16 14 12 10 8 6 4 2 0 11 8 2 5 14 6 14 5 16 4 8 2 5 1 6 4 Early Complications Late Complications REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 74 primary reason given for having abortions was “want- ing no more children,” indicating that the pregnancies were unintended ---- another indication of insufficient family planning services in the country. Compared to 1999 (Figure 5.5.2), proportionately more abortions now are for spacing, or are done for health reasons. Fortunately, partner related reasons are very minor, indicating that women independently make the de- cision to have an abortion or are in agreement with their partner. In conclusion, survey-based abortion estimates in Georgia are still higher than the official statistics, presumably because government reporting systems from which official statistics are derived suffer from underreporting. Because it is likely that some abortion under-reporting has also taken place in the survey, survey-based levels of abortion should be viewed as conservative estimates of the true magnitude of abor- tion practices at the population level. Beyond provid- ing a more accurate documentation of abortion levels and trends, survey estimates have broader scope re- garding the burden of unwanted pregnancy and the need for increased access to and use of contraceptive services. The 2010 Georgia survey shows that since 2005, bet- ter access to contraception has already led to a reduc- tion in unintended pregnancy and a decrease in the national abortion rate. The fact that an increasing proportion of women having abortions are living in rural areas, are poor and less educated, underscores the importance of subsidized family planning services and expanded coverage of these services as effective means of reducing the incidence of both unintended pregnancy and abortion. The ICPD Programme of Ac- tion urges countries to reduce the recourse to abor- tion through availability of post-abortion counseling, Most important Reason for Having an Induced Abortion Among Women Aged 15 – 44 With at Least one Abortion in the Past 5 Years: Eastern Europe RHS Survey Data and GERHS2010 Figure 5.5.1 Percentage Moldova 70 60 50 40 30 20 10 0 Roamnia Ukraine Azerbaijan Georgia 2005 Georgia 2010 28 57 7 8 53 30 11 7 63 32 1 4 66 29 2 4 51 20 2 8 66 29 2 4 Limit fertility Socioeconomic Partner-related Health-related % of Induced Abortions Most Important Reason for Pregnancy Termination Among Abortions Performed in the Last 5 Years Georgia, 1999, 2005, and 2010 Figure 5.5.2 Limit Fertility Socioeconomic Space Birth Health-related 1999 2005 2010 Partner-related 66 63 51 20 15 20 9 19 18 4 2 8 1 0.4 2 FINAL REPORT 75 education, and family-planning. Since 1999, Georgia has made substantial progress: abortion rates have been falling while more women have adopted mod- ern contraception and fewer have an unmet need for modern contraception. Still, more efforts are needed to achieve further reduction in abortion rates, particu- larly when half of abortions occur because the woman does not want any more children. However, family planning cannot prevent all unintend- ed pregnancies because no contraceptive method is perfectly fail-safe. Reliance on traditional methods of contraception—common among the rural, poor, and less educated women —is particularly associ- ated with method-failure and subsequent abortion. While the national family planning efforts need to be intensified and users of traditional methods need to be educated about the availability of more effective methods, access to safe abortion should continue to be made available. Worldwide, abortions performed in safe conditions are associated with very low rates of morbidity and mortality. Efforts to further replace abortion with contraception should focus on increas- ing access to a variety of high quality, affordable birth control methods and not on limiting availability of safe abortion services. Table 5.1 2007–2010 GERHS10† 2002–2005 GERHS05‡ 1996–1999 GERHS99¶  15–19 10 13 29 20–24 56 126 162 25–29 102 164 191 30–34 83 167 179 35–39 57 110 122 40–44 (21) (54) (49) Total Abortion Rate 1.6 3.1 3.7 General Abortion Rate (per 1,000 Women/Year) 56 104 125 * Age at induced abortion. † Abortions occurring between October 2007 and September 2010. ‡ Abortions occurring between March 2002 and February 2005. ¶ Abortions occurring between December 1996 and November 1999. ( ) Time exposed partially truncated because the sample does not include all women exposed during the reference period. Age–Specific Induced Abortion Rate (per 1,000)* Age Group Three–Year Age–Specific Abortion Rates and Total Abortion Rates for Three Time Periods among All Women Aged 15–44 Reproductive Health Survey: Georgia, 1999, 2005, 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 76 Table 5.2.1 Three–Year Period Age–Specific Abortion Rates and Total Abortion Rates* by Selected Characteristics among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 15–19 20–24 25–29 30–34 35–39 40–44 Total 10 56 102 83 57 21 1.6 Residence Urban 6 42 62 74 41 16 1.2 Rural 14 71 150 93 74 26 2.1 Region Kakheti 30 58 100 46 135 18 1.9 Tbilisi 9 44 53 73 36 13 1.1 Shida Kartli 7 133 144 72 61 22 2.2 Kvemo Kartli 11 53 170 111 106 19 2.4 Samtskhe–Javakheti 3 40 77 95 70 37 1.6 Adjara 0 51 87 49 20 32 1.2 Guria 12 59 156 144 44 7 2.1 Samegrelo 6 77 169 92 48 18 2.1 Imereti 10 47 101 96 40 32 1.6 Mtskheta–Mtianeti 8 77 113 127 58 13 2.0 Racha–Svaneti 13 21 43 81 60 0 1.1 Education Level Secondary incomplete or less 14 125 186 85 89 32 2.7 Secondary complete 10 76 151 107 110 19 2.4 Technicum 4 54 68 85 40 28 1.4 University/Postgraduate 4 26 62 70 29 11 1.0 Wealth Quintile Lowest 12 72 179 79 70 33 2.2 Second 13 61 139 86 73 24 2.0 Middle 10 71 113 101 59 22 1.9 Fourth 11 55 71 62 57 14 1.4 Highest 3 32 52 82 38 14 1.1 Ethnicity Georgian 7 51 90 82 52 20 1.5 Azeri 45 92 207 132 144 46 3.3 Armenian 12 27 146 80 82 0 1.7 Other 30 212 168 17 41 25 2.5 * Abortions occurring between October 2007 and September 2010. † Age at induced abortion. Age–Specific Induced Abortion Rate (per 1,000)† Characteristic Total Abortion Rate (Abortions per Woman) FINAL REPORT 77 Table 5.2.2 Women Aged 15–44 Who Had at Least One Abortion and Number of Lifetime Abortions by Selected Characteristics Reproductive Health Survey: Georgia, 2010 1 2 3 4 5–6 7–9 10+ Total 37.1 6,292 31.4 23.5 15.4 9.1 10.0 4.3 6.3 100.0 2,568 Region Tbilisi 31.8 1,426 38.8 22.0 15.2 8.3 7.0 3.2 5.5 100.0 490 Other Urban 35.4 1,549 30.2 26.0 16.9 8.1 9.7 5.1 3.9 100.0 594 Rural 41.2 3,317 28.6 23.1 14.8 9.8 11.5 4.4 7.8 100.0 1,484 Age Group 15–19 2.2 861 85.6 14.4 0.0 0.0 0.0 0.0 0.0 100.0 25 20–24 13.8 1,099 55.3 29.3 6.4 6.7 2.3 0.0 0.0 100.0 186 25–29 35.5 1,191 44.4 23.7 15.9 5.8 6.1 2.2 1.8 100.0 436 30–34 54.6 1,168 30.9 24.0 14.9 9.0 11.5 4.8 4.9 100.0 663 35–39 60.6 1,051 23.1 25.3 16.2 11.2 11.4 5.2 7.6 100.0 637 40–44 67.6 922 23.5 20.1 17.7 10.0 12.1 5.7 10.8 100.0 621 Number of Living Children None 3.4 2,276 68.9 17.0 6.2 7.9 0.0 0.0 0.0 100.0 96 One 39.4 1,286 53.4 21.6 11.5 4.6 4.6 3.3 1.0 100.0 518 Two 69.5 2,069 24.8 24.4 17.9 10.3 11.0 4.6 7.0 100.0 1,456 Three 77.5 539 18.8 23.4 15.8 11.7 15.4 4.7 10.2 100.0 417 Four or more 68.5 122 30.2 28.2 6.7 3.6 9.5 8.9 12.8 100.0 81 Education Level Secondary incomplete or less 32.0 1,330 24.5 21.3 15.4 10.1 12.6 4.6 11.6 100.0 486 Secondary complete 39.1 1,568 33.7 24.6 12.7 8.2 10.2 5.8 4.8 100.0 691 Technicum/University 38.4 3,394 32.8 23.8 16.7 9.1 9.0 3.5 5.0 100.0 1,391 Wealth Quintile Lowest 40.8 1,093 28.9 25.1 13.6 8.9 11.1 3.7 8.8 100.0 469 Second 39.4 1,385 27.9 25.3 16.2 7.9 10.6 4.4 7.8 100.0 602 Middle 40.2 1,413 29.0 21.7 14.6 11.8 11.4 5.4 6.1 100.0 620 Fourth 31.4 1,037 35.8 23.8 15.1 8.1 8.8 3.7 4.7 100.0 369 Highest 34.8 1,364 35.5 22.6 16.9 8.1 8.3 4.1 4.5 100.0 508 Ethnicity Georgian 36.5 5,488 32.0 23.8 15.6 9.3 10.0 4.0 5.3 100.0 2,197 Azeri 47.2 276 20.0 18.4 18.4 7.6 13.8 4.9 16.9 100.0 143 Armenian 35.4 364 38.7 26.5 8.9 9.8 3.5 5.7 6.9 100.0 150 Other 42.3 164 26.2 23.2 15.0 3.4 12.9 9.2 10.2 100.0 78 No. of CasesEver Had an AbortionCharacteristic No. of Cases Number of Lifetime Induced Abortions Among Women Who Have Ever Had an Abortion Total REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 78 Table 5.2.3 Gestational Age at the Time of Pregnancy Termination by Selected Characteristics Among Pregnancies Ended in Abortion in 2005–2010 Reproductive Health Survey: Georgia, 2010 < 7 7–9 10–12 13+ Total 27.9 59.2 11.9 1.1 100.0 2,054 Residence Tbilisi 30.7 60.4 7.9 1.0 100.0 333 Other Urban 29.8 60.7 8.0 1.5 100.0 435 Rural 26.1 58.2 14.8 0.9 100.0 1,286 Age Group 15–19 17.9 70.3 11.9 0.0 100.0 18 20–24 21.5 63.8 13.4 1.2 100.0 208 25–29 32.7 56.4 9.9 1.0 100.0 540 30–34 25.2 62.6 11.2 1.1 100.0 648 35–39 29.9 57.1 12.5 0.5 100.0 424 40–44 26.8 55.2 15.7 2.2 100.0 216 Number of Living Children None 46.2 48.4 5.4 0.0 100.0 9 One 27.6 58.6 10.7 3.1 100.0 334 Two 29.9 59.5 9.8 0.7 100.0 1,280 Three 24.7 58.2 16.5 0.6 100.0 350 Four or more 9.5 61.6 28.9 0.0 100.0 81 Education Level Secondary incomplete or less 26.1 56.0 17.0 1.0 100.0 456 Secondary complete 23.8 63.5 12.4 0.3 100.0 668 Technicum/University 31.6 57.8 8.9 1.7 100.0 930 Wealth Quintile Lowest 17.6 61.9 19.8 0.7 100.0 419 Second 29.8 58.3 11.1 0.8 100.0 504 Middle 27.4 59.3 12.4 0.9 100.0 506 Fourth 26.8 66.1 5.3 1.8 100.0 282 Highest 36.0 52.6 10.2 1.3 100.0 343 Ethnicity Georgian 29.8 58.9 10.0 1.2 100.0 1,661 Azeri 25.8 59.1 14.6 0.5 100.0 181 Armenian 18.8 59.1 21.1 1.0 100.0 141 Other 8.2 63.9 27.9 0.0 100.0 71 Pregnancy end Induced abortion 2.6 53.6 40.2 3.6 100.0 645 Mini-abortion 38.3 61.5 0.2 0.0 100.0 1,409 Characteristic Gestational Age (in Week) Total No. of Cases FINAL REPORT 79 Table 5.3.1 Induced abortion Mini-abortion Total No. of Cases Total 29.3 70.7 100.0 2,054 Residence Urban 19.3 80.7 100.0 768 Rural 36.6 63.4 100.0 1,286 Region Kakheti 43.4 56.6 100.0 185 Tbilisi 18.7 81.3 100.0 333 Shida Kartli 17.1 82.9 100.0 183 Kvemo Kartli 31.4 68.6 100.0 253 Samtskhe-Javakheti 50.8 49.2 100.0 160 Adjara 19.6 80.4 100.0 90 Guria 47.4 52.6 100.0 163 Samegrelo 40.5 59.5 100.0 169 Imereti 27.0 73.0 100.0 265 Mtskheta-Mtianeti 22.2 77.8 100.0 152 Racha-Svaneti 45.8 54.2 100.0 101 Characteristic Type of Pregnancy Termination by Selected Characteristics among Pregnancies Ended in Abortion in 2005–2010 Reproductive Health Survey: Georgia, 2010 Type of Pregnancy Termination Racha-Svaneti 45.8 54.2 100.0 101 Age Group 15–24 28.6 71.4 100.0 501 25–34 27.9 72.1 100.0 1,196 35–44 34.3 65.7 100.0 357 Order of Abortion First 28.8 71.2 100.0 576 Second 26.5 73.5 100.0 417 Third 27.2 72.8 100.0 291 Fourth 31.8 68.2 100.0 185 Fifth 32.3 67.7 100.0 135 Sixth or higher 31.8 68.2 100.0 450 Education Secondary complete or less 34.6 65.4 100.0 1,124 Technicum 33.1 66.9 100.0 286 University/Postgraduate 18.7 81.3 100.0 644 Wealth quintile Lowest 46.8 53.2 100.0 419 Second 31.8 68.2 100.0 504 Middle 29.1 70.9 100.0 506 Fourth 13.8 86.2 100.0 282 Highest 22.6 77.4 100.0 343 Ethnicity Georgian 27.4 72.6 100.0 1,661 Azeri 37.2 62.8 100.0 181 Armenian 38.1 61.9 100.0 141 Other 34.0 66.0 100.0 71 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 80 Table 5.3.2 Hospital/ Maternity Ward Ambulatory Clinics Outside a Medical Facility Total No. of Cases Total 55.8 42.2 1.9 100.0 2,054 Residence Urban 38.6 59.6 1.8 100.0 768 Rural 68.4 29.6 2.0 100.0 1,286 Residence Tbilisi 29.4 69.6 1.0 100.0 333 Other Urban 46.9 50.7 2.4 100.0 435 Rural 68.4 29.6 2.0 100.0 1,286 Region Kakheti 71.2 23.2 5.6 100.0 185 Tbilisi 29.4 69.6 1.0 100.0 333 Shida Kartli 59.0 40.5 0.5 100.0 183 Kvemo Kartli 60.1 37.5 2.4 100.0 253 Samtskhe-Javakheti 72.4 27.1 0.6 100.0 160 Adjara 47.3 46.4 6.3 100.0 90 Guria 75.5 21.9 2.6 100.0 163 Samegrelo 51.6 47.9 0.5 100.0 169 Imereti 69.3 30.0 0.7 100.0 265 Mtskheta Mtianeti 54.0 44 9 1.1 100.0 152 Place of Pregnancy Termination by Selected Characteristics among Pregnancies Ended in Abortion in 2005–2010 Reproductive Health Survey: Georgia, 2010 Characteristic Place of Pregnancy Termination Mtskheta-Mtianeti 54.0 44.9 1.1 100.0 152 Racha-Svaneti 88.8 10.3 0.9 100.0 101 Age Group (at Abortion) 15–24 62.2 36.9 0.9 100.0 501 25–34 53.4 44.2 2.4 100.0 1,196 35–44 55.3 43.1 1.6 100.0 357 Order of Abortion First 58.1 40.5 1.4 100.0 576 Second 52.4 46.3 1.3 100.0 417 Third 51.9 45.6 2.4 100.0 291 Fourth 53.1 44.7 2.3 100.0 185 Fifth 61.2 37.2 1.5 100.0 135 Sixth or higher 58.1 39.3 2.7 100.0 450 Education Secondary complete or 60.4 37.1 2.5 100.0 1,124 Technicum 58.4 40.6 1.0 100.0 286 University/Postgraduate 47.0 51.8 1.2 100.0 644 Wealth quintile Lowest 76.0 22.7 1.3 100.0 419 Second 68.4 29.6 2.0 100.0 504 Middle 55.0 41.0 4.0 100.0 506 Fourth 43.3 55.7 1.1 100.0 282 Highest 34.3 65.2 0.5 100.0 343 Ethnicity Georgian 54.0 44.0 2.0 100.0 1,661 Azeri 77.4 20.5 2.1 100.0 181 Armenian 59.0 39.5 1.4 100.0 141 Other 33.4 66.7 0.0 100.0 71 Type of Abortion Induced abortion 65.9 30.5 3.5 100.0 645 Mini-abortion 51.7 47.1 1.2 100.0 1,409 FINAL REPORT 81 Table 5.3.3 Any Method % Any Traditional Method % Any Modern Method % Total 26.4 20.1 15.6 2,054 Residence Urban 26.6 17.4 18.9 768 Rural 26.2 22.1 13.2 1,286 Region Kakheti 20.2 15.2 12.1 185 Tbilisi 26.1 14.3 21.7 333 Shida Kartli 16.1 13.7 13.2 183 Kvemo Kartli 34.1 28.7 14.3 253 Samtskhe-Javakheti 49.2 41.4 12.7 160 Adjara 25.0 20.5 5.4 90 Guria 19.8 15.1 9.9 163 Samegrelo 11.1 7.9 6.8 169 Imereti 32.3 26.0 24.3 265 Mtskheta-Mtianeti 26.1 22.7 15.3 152 R h S ti 34 6 29 9 15 0 101 Contraceptive Use No. of CasesCharacteristic Use of Contraception at the Time of Conception by Selected Characteristics Among Pregnancies Ended in Abortion in 2005–2010 Reproductive Health Survey: Georgia, 2010 Racha-Svaneti 34.6 29.9 15.0 101 Age at Abortion 15–24 23.9 16.1 15.1 501 25–34 25.2 18.9 15.6 1,196 35–44 33.2 29.0 16.1 357 Education Secondary complete or less 24.3 20.5 10.3 1,124 Technicum 26.2 21.0 19.5 286 University/Postgraduate 30.0 19.2 23.2 644 Wealth quintile Lowest 28.7 24.9 14.7 419 Second 23.4 20.6 9.8 504 Middle 23.8 20.0 11.7 506 Fourth 23.4 14.7 18.8 282 Highest 32.9 19.4 25.1 343 Ethnicity Georgian 26.5 19.4 18.5 1,661 Azeri 28.5 27.5 2.5 181 Armenian 35.0 28.5 8.7 141 Other 7.2 4.9 4.0 71 Pregnancy ended by Induced abortion 22.5 18.8 11.7 645 Mini-abortion 28.0 20.7 17.2 1,409 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 82 Table 5.3.4 Cost of a Procedure for Pregnancy Termination by Selected Characteristics Among Pregnancies Ended in Abortion in 2005–2010 Reproductive Health Survey: Georgia, 2010 None < 30 30–34 35–49 50–99 100 or more Do not Remember Total No. of Cases Total 48.2 2.3 12.6 16.0 22.6 39.4 5.9 1.3 100.0 2,054 Residence Tbilisi 61.5 3.1 4.1 7.4 18.9 49.1 15.3 2.0 100.0 333 Other Urban 46.0 1.9 12.2 18.2 23.3 39.3 4.4 0.7 100.0 435 Rural 44.5 2.2 15.7 18.1 23.6 36.0 3.2 1.3 100.0 1,286 Age group (at Abortion) 15–24 50.8 1.6 9.7 14.1 23.7 43.5 6.3 1.1 100.0 501 25–34 46.2 2.7 15.1 15.5 22.1 38.5 4.8 1.3 100.0 1,196 35–44 51.2 1.9 8.7 19.6 22.9 37.0 8.5 1.4 100.0 357 Order of Abortion First 53.2 3.1 8.3 12.3 19.0 46.5 9.1 1.7 100.0 576 Second 50.6 1.1 11.2 14.5 24.4 40.5 6.7 1.6 100.0 417 Third 49.5 1.9 13.9 14.8 21.1 41.8 5.5 1.1 100.0 291 Fourth 45.6 2.0 12.5 19.5 26.8 34.1 4.4 0.7 100.0 185 Fifth 43.6 2.3 15.4 17.1 26.4 37.2 1.6 0.0 100.0 135 Sixth or higher 41.8 2.7 17.3 20.6 23.6 31.2 3.3 1.4 100.0 450 Education Level Secondary incomplete 47 1 2 2 11 2 22 6 22 6 33 8 6 4 1 3 Characteristic Cost of Abortion (in GEL)* Mean Payment† Secondary incomplete or less 47.1 2.2 11.2 22.6 22.6 33.8 6.4 1.3 100.0 456 Secondary complete 45.6 1.9 14.7 15.1 24.4 38.5 3.9 1.5 100.0 668 Technicum/University 50.7 2.6 11.9 13.1 21.4 42.9 7.0 1.2 100.0 930 Wealth Quintile Lowest 40.6 2.5 20.7 20.8 22.8 30.7 2.4 0.2 100.0 419 Second 42.6 2.0 12.2 21.0 22.7 39.8 1.0 1.3 100.0 504 Middle 49.2 2.0 16.1 14.5 23.9 35.1 5.9 2.5 100.0 506 Fourth 49.5 2.9 6.0 11.0 27.0 47.0 5.0 1.0 100.0 282 Highest 59.3 2.3 6.8 11.3 17.6 45.8 15.0 1.2 100.0 343 Ethnicity Georgian 48.5 2.2 12.0 16.0 22.9 40.6 5.5 0.9 100.0 1,661 Azeri 40.2 3.6 22.1 21.8 14.5 32.7 2.5 2.8 100.0 181 Armenian 49.0 3.7 9.0 9.9 23.9 47.2 4.9 1.5 100.0 141 Other 62.3 0.0 4.8 9.7 35.5 23.2 21.5 5.2 100.0 71 Type of Abortion Induced Abortion 54.8 3.3 12.4 15.3 16.7 39.5 11.4 1.4 100.0 645 Mini-abortion 45.5 1.9 12.7 16.2 25.0 39.3 3.6 1.3 100.0 1,409 Abortion Facility Hospital/ maternity 48.2 1.4 14.2 17.6 22.0 36.8 6.8 1.2 100.0 1,207 Ambulatory clinics 49.2 1.2 10.4 14.1 24.1 43.9 4.8 1.5 100.0 810 Outside a medical 26.6 53.3 14.0 10.1 7.5 13.1 2.0 0.0 100.0 37 Gestational Age 10 weeks or more 64.8 1.4 7.1 13.4 17.5 39.9 18.5 2.2 100.0 291 <10 weeks 45.8 2.4 13.4 16.3 23.4 39.3 4.0 1.2 100.0 1,763 Antibiotics– Abortion Yes 53.5 1.8 11.1 13.9 18.7 43.9 9.2 1.3 100.0 845 No 44.5 2.6 13.7 17.4 25.3 36.1 3.5 1.3 100.0 1,209 * At the time of the survey approximately 1.65 GEL=1.00 USD † Mean payment per procedure does not include payments of unknown amount. FINAL REPORT 83 Table 5.3.5 Any Counseling Before Abortion After Abortion Method Distributed Prescription Offered Referral Offered Total 33.1 9.9 13.2 6.6 7.4 2.7 2,054 Residence Urban 35.6 10.5 13.6 6.1 9.2 3.3 768 Rural 31.3 9.4 12.8 6.9 6.1 2.3 1,286 Region Kakheti 25.8 4.5 10.6 7.6 4.5 1.5 185 Tbilisi 36.3 9.7 11.8 4.1 9.7 1.5 333 Shida Kartli 40.0 13.2 19.0 4.4 9.8 1.0 183 Kvemo Kartli 25.6 7.8 14.7 4.4 9.2 2.4 253 Samtskhe-Javakheti 13.8 5.5 5.0 4.4 2.8 0.0 160 Adjara 33.0 17.0 9.8 5.4 7.1 5.4 90 Guria 29.2 8.9 9.9 5.2 1.6 4.2 163 Samegrelo 30.0 4.2 15.8 5.3 1.6 4.7 169 Imereti 45.7 15.0 15.7 15.7 10.0 4.7 265 Mtskheta Mtianeti 31 8 10 8 8 5 2 3 3 4 0 0 152 Contraception Counseling Distribution of Contraceptive Methods, Prescriptions for Methods, or Referrals Selected Family Planning Services Offered at the Time of Legally Performed Abortions Characteristic by Selected Characteristics among Pregnancies Ended in Abortion in 2005–2010 No. of Cases Reproductive Health Survey: Georgia, 2010 Mtskheta-Mtianeti 31.8 10.8 8.5 2.3 3.4 0.0 152 Racha-Svaneti 29.9 2.8 13.1 5.6 12.1 3.7 101 Age Group (at Abortion) 15–24 33.7 11.3 13.5 7.9 8.1 3.4 501 25–34 34.0 8.8 13.9 6.2 8.2 2.3 1,196 35–44 29.7 11.3 10.4 6.1 4.2 3.0 357 Education Secondary complete or less 32.3 9.3 13.6 6.3 7.2 2.1 1,124 Technicum 27.1 7.7 8.1 3.7 7.5 0.9 286 University/Postgraduate 36.8 11.7 14.5 8.2 7.7 4.3 644 Wealth quintile Lowest 25.2 9.9 8.9 4.9 5.0 1.8 419 Second 35.5 9.4 14.7 11.1 6.3 4.1 504 Middle 32.0 8.4 16.5 5.1 7.5 1.1 506 Fourth 37.1 10.3 12.5 5.6 8.1 6.2 282 Highest 35.6 11.7 12.0 5.4 10.3 1.0 343 Ethnicity Georgian 34.9 10.5 13.4 7.6 6.9 3.2 1,661 Azeri 28.4 7.7 13.7 3.7 9.7 0.0 181 Armenian 26.3 9.0 13.7 1.9 8.9 1.9 141 Other 21.2 4.2 7.2 1.1 8.6 1.1 71 Order of Abortion First 30.5 10.5 12.1 7.4 7.0 3.7 576 Second 34.4 12.4 12.7 7.5 9.6 2.9 417 Third 30.6 9.0 11.9 5.6 5.2 1.2 291 Fourth-fifth 38.2 11.4 14.7 8.8 7.7 3.1 320 Sixth or higher 33.2 6.4 14.6 4.1 7.3 1.9 450 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 84 Table 5.3.6 Use of Ultrasound Prior to the Pregnancy Termination by Selected Characteristics Among Pregnancies Ended in Abortion in 2005–2010 Reproductive Health Survey: Georgia, 2010 Characteristic Had Ultrasound Assessment of Gestational Age Had Ultrasound Assessment of Gender No. of Cases Total 51.8 3.3 2,054 Residence Urban 67.1 4.6 768 Rural 40.5 2.4 1,286 Residence Tbilisi 82.4 4.9 333 Other Urban 53.4 4.3 435 Rural 40.5 2.4 1,286 Age Group (at Abortion) 15–24 52.1 2.7 501 25–34 51.4 2.9 1,196 35–44 52.7 5.1 357 Number of Living Children 0 * * 9 1 64.2 1.8 334 2 52.3 2.9 1,280 3 43.1 2.6 350 4 or more 32.9 20.0 81 Education Level Secondary incomplete or less 44.2 5.0 456 Secondary complete 43.0 4.1 668 Technicum/University 61.9 1.9 930 Wealth Quintile Lowest 33.3 2.2 419 Second 36.8 1.8 504 Middle 49.9 4.8 506 Fourth 70.1 3.0 282 Highest 73.4 4.5 343 Ethnicity Georgian 55.9 2.8 1,661 Azeri 25.1 3.5 181 Armenian 30.6 3.9 141 Other 68.6 10.8 71 Type of Abortion Induced abortion 43.9 8.5 645 Mini-abortion 55.0 1.1 1,409 Abortion Facility Hospital/maternity ward 47.8 3.4 1,207 Ambulatory clinics 58.2 3.0 810 Outside a medical facility 26.9 6.5 37 Gestational Age <10 weeks 50.7 1.3 1,763 10+ 58.7 16.8 291 * Fewer than 25 cases in this category. FINAL REPORT 85 Table 5.4.1 Abortion Clinical Practice and Prevalence of Early and Late Complications by Selected Characteristics Among Pregnancies Ended in Abortion in 2005–2010 Reproductive Health Survey: Georgia, 2010 Anesthesia Antibiotic Treatment One or More Nights Hospitalized No. of Cases Early Complications No. of Cases Late Complications No. of Cases* Total 56.6 41.5 0.6 2,054 6.4 2,054 3.6 2,020 Residence Tbilisi 59.1 50.1 0.5 333 6.9 333 2.6 328 Other Urban 58.2 44.3 0.8 435 5.4 435 3.0 430 Rural 55.1 37.5 0.6 1,286 6.6 1,286 4.2 1,262 Age Group (at Abortion) 15–24 59.7 43.3 0.1 501 5.3 501 2.9 493 25–34 56.0 40.6 0.9 1,196 6.6 1,196 3.1 1,176 35–44 54.6 42.2 0.6 357 7.0 357 5.9 351 Order of Abortion First 62.4 43.6 0.5 576 5.8 576 2.8 560 Second 58.0 41.6 1.1 417 6.8 417 3.8 414 Third 52.8 43.8 0.8 291 6.6 291 4.3 290 Fourth 57.6 47.7 0.0 185 6.3 185 4.6 181 Fifth 53.9 46.0 0.0 135 5.2 135 2.3 135 Sixth or higher 51.1 34.1 0.6 450 6.9 450 3.9 440 Education Level Secondary incomplete or less 58.3 33.4 0.0 456 4.1 456 3.4 448 Secondary complete 54.5 41.9 0.9 668 8.6 668 4.1 653 Technicum/ University 57.2 45.5 0.8 930 6.0 930 3.4 919 Wealth Quintile Lowest 51.6 35.6 0.6 419 5.0 419 3.2 407 Second 46.8 33.4 0.6 504 7.1 504 3.8 496 Middle 64.8 39.4 0.3 506 6.4 506 4.5 503 Fourth 56.0 45.6 1.0 282 3.8 282 2.8 275 Highest 63.0 55.2 0.8 343 8.7 343 3.4 339 Ethnicity Georgian 58.3 45.0 0.6 1,661 6.6 1,661 3.5 1,636 Azeri 40.9 20.4 0.5 181 5.8 181 5.5 177 Armenian 60.4 24.7 0.5 141 6.5 141 2.1 136 Other 58.5 51.3 1.1 71 3.2 71 3.2 71 Type Abortion Induced Abortion 68.1 40.7 1.0 645 9.5 645 6.6 638 Mini-abortion 51.8 41.9 0.5 1,409 5.1 1,409 2.3 1,382 Where Abortion Hospital/ maternity Ward 58.3 41.3 0.4 1,207 6.6 1,207 4.2 1,185 Ambulatory clinics 55.3 42.9 0.9 810 6.1 810 2.7 799 Outside a Medical Facility 35.1 18.4 0.0 37 7.5 37 5.3 36 Gestational Age <10 weeks 53.3 40.7 0.6 1,763 6.1 1,763 2.6 1,734 10+ 79.0 47.0 0.9 291 8.2 291 10.1 286 Early Complications Absent 56.2 39.9 0.0 1,928 0.0 1,928 1.4 1,897 Present 62.2 65.1 9.8 126 100.0 126 36.4 123 * Includes sequelae at six months after the abortion (96 cases with less than six months since abortion were excluded). Respondents experiencing more than one type of complication were asked to report only the most severe Postabortion ComplicationsClinical Practice Characteristic REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 86 Table 5.4.2 Induced Abortions Performed in 2005–2010 by Type of Early Complications and by Gestational Age – Reproductive Health Survey: Georgia, 2010 < 7 weeks 7 or more Prolonged pelvic pain 58.6 50.4 62.0 Fever (over 38o) 36.7 27.3 40.6 Severe Bleeding 34.5 32.7 35.2 Infectious vaginal discharge 22.3 36.1 16.7 Perforation 1.7 0.0 2.4 Other problem 4.1 2.6 4.7 No. of Abortions with Early Complications 126 30 96 Characteristic Total Gestational Age (in weeks) Table 5.5 Most Important Reason for Abortions Performed in 2005–2010 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Want No (More) Children Socioeconomic Reasons Want to Postpone Childbearing Risk to Maternal or Fetal Health Partner Objected to Pregnancy Sex Selection Total 51.1 20.2 18.1 7.8 1.5 1.4 100.0 2,054 Residence Tbilisi 46.3 24.0 14.3 9.7 2.8 2.8 100.0 333 Other Urban 46.6 17.1 21.7 12.1 1.1 1.5 100.0 435 Rural 54.5 20.0 18.0 5.4 1.1 0.9 100.0 1,286 Age Group (at Abortion) 15–24 33.9 17.1 38.3 9.3 0.1 1.3 100.0 501 25–34 54.7 21.5 13.8 6.8 2.2 1.0 100.0 1,196 35–44 61.7 20.0 5.7 8.7 0.9 3.0 100.0 357 Wealth Quintile Lowest 54.9 25.1 13.0 5.5 0.5 1.0 100.0 419 Second 53.5 19.1 22.5 3.8 0.6 0.5 100.0 504 Middle 53.3 18.3 19.4 5.0 2.1 1.9 100.0 506 Fourth 45.2 23.3 19.4 11.4 0.0 0.7 100.0 282 Highest 46.9 16.9 15.2 14.6 3.6 2.7 100.0 343 Order of All the Pregnancies First * * * * * * 100.0 20 Second 18.0 12.9 55.2 10.9 2.9 0.0 100.0 240 Third 40.0 18.1 28.0 12.0 0.4 1.5 100.0 329 Fourth 50.0 20.5 16.5 9.8 1.1 2.1 100.0 328 Fifth or Higher 61.7 22.3 8.5 4.5 1.6 1.4 100.0 1,137 No. of Cases * Fewer than 25 cases in this t Characteristic Reason for Abortion Total 87 CHAPTER 6 MATERNAL AND CHILD HEALTH Pregnancy and childbirth complications are the lead- ing cause of disability and death for women of repro- ductive age in developing countries. The World Health Organization (WHO) documents an enormous toll of maternal and child mortality and morbidity world- wide: An estimated 358,000 maternal deaths occurred during pregnancy, childbirth, or the postnatal period in 2008, down from 546,000 in 1990 (WHO, 2010a). Approximately 8.8 million children die every year be- fore their fifth birthday, including 3.8 million infants who died during the first 28 days after birth, 1.8 who died in the postneonatal period but before one year of age, and 3.2 million who died after the first but be- fore the fifth birthday (You et al., 2010; UNICEF, 2009). The health and survival of newborn children is closely linked to that of their mothers because lack of care or inadequate care during pregnancy, childbirth, and the postpartum period is associated with inadequate postnatal infant care; children whose mothers die of pregnancy related causes are more likely to die than those whose mothers are still alive (UNICEF, 2005). A number of factors can impact the health of a wom- an, the health of her baby, and the outcome of her pregnancy, including utilization of health care ser- vices related to pregnancy, location and type of assis- tance at delivery, and postpartum behaviors, includ- ing breastfeeding. As with previous survey rounds in Georgia, the 2010 study collected detailed informa- tion regarding the actual experiences of respondents during pregnancy, delivery, and the postpartum peri- od. These topics, as well as infant and child mortality, are examined in this chapter. All estimates reported here are based on respondents’ reports as recorded in a lifetime pregnancy history and a detailed birth histo- ry for all births carried to term since January 2005. Be- cause of the limited sample size and the fertility and mortality levels (which are not very high), the mater- nal mortality ratio cannot be directly estimated using a survey-based approach (i.e. the sisterhood method). Figures presented here are based on official reports and on the nationwide Reproductive Age Mortality Survey (RAMOS) of female deaths aged 15–49 in 2006 (Serbanescu et al., 2009) 6.1 Maternal Mortality Statistics Five years before the deadline to achieve the Millen- nium Development Goals, the reduction of maternal mortality by three-quarters and the under-five mor- tality by two-thirds between 1990 and 2015 remain elusive targets for most countries. In Georgia, for ex- ample, the official maternal mortality ratio increased by almost 20% between 1990 and 2000 (from 41 to REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 88 49 maternal deaths per 100,000 live births), with a peak rate in 1997 (70.6 maternal deaths per 100,000 live births). From 2000-2008 the rate fell substantial- ly, only to increase abruptly in 2009 to 51 deaths per 100,000 live births, higher than in 1990 (Figure 6.1). The official source for maternal mortality levels and trends is the civil registration system, which records deaths by cause on a continuous basis. The Georgian Ministry of Labor, Health, and Social Affairs (MoLHSA), which monitors the number of maternal deaths in the health management information system, generally reports similar figures. The recent RAMOS conducted in 2008-2009 showed that both under-reporting of all deaths and misclassification of causes of death are important sources of error in the measurements of maternal mortality. The study identified deaths us- ing multiple sources and investigated these deaths by completing detailed family questionnaires with rela- tives of the deceased women and conducting inter- views and record reviews at the medical facilities that provided care prior to death. The study identified 2.8 times more maternal deaths in 2006 than officially re- ported (MMR=66/100,000); 68% of maternal deaths followed deliveries, 16% followed other pregnancy outcomes, and 16% were undetermined. Hemor- rhage, puerperal infection, and pregnancy-induced hypertension accounted for most direct obstetric ma- ternal deaths; about 40% of deaths were due to indi- rect causes, most of them not captured in the official statistics (Serbanescu et al., 2009). 6.2 Prenatal Care Prenatal care is important for preventing, identifying, and treating conditions that can affect the health of an expectant mother or her baby. To ensure optimal health of mother and child, experts recommend that prenatal care be initiated during the first trimester of pregnancy, continue throughout gestation at specified intervals, and be comprehensive (i.e., includes risk as- sessment, risk reduction or treatment of medical con- ditions, and counseling). Comprehensive prenatal care can decrease perinatal maternal and infant morbidity and mortality by identifying and addressing potential risk factors that contribute to poor outcomes. Popu- lation-based surveys conducted in former Soviet-bloc countries since the breakup of the Soviet Union have documented very high prenatal care coverage in the region, with only one country (Azerbaijan) reporting a relatively high proportion of pregnant women with no prenatal care (Figure 6.2.1) (CDC and Macro, 2003). Until 1995, recommendations for prenatal care in Georgia followed the standards set by the Soviet Un- ion, which were similar to those used in industrialized countries. Standard prenatal care (for uncomplicat- ed pregnancies) included routine visits according to gestational age, as follows: monthly visits before 12 weeks of pregnancy; bi-monthly visits from 12 to 30 weeks of gestation; and weekly or bi-monthly visits until delivery. In Georgia the transition of the health care system from support by government financing to a payroll- tax–based system led to the adoption of a new four- visit prenatal care protocol in 1996, which was later modified according to WHO recommendations intro- duced in 2002 (WHO, 2002). The new WHO prenatal care model recommends that the first prenatal care visit include a comprehensive assessment of health conditions and potential risk factors to classify preg- nant women into two groups: those who will follow the basic prenatal care program (about 75% of all pregnant women) and those who need referral to a 1995 1997 1999 2001 2003 2005 2009 80 70 60 50 40 30 20 10 0 Maternal Deaths per 100.000 Live Births Maternal Mortality in Georgia Official Estimates and RAMOS Estimates for 1995–2009 Figure 6.1 2007 55.1 50.5 52.0 65.6 SDS MoLHSA RAMOS Source: SDS estimates available at http://statistics.ge; Georgian MoLHSA estimates in L. Sakvarelidze, 2010; RAMOS estimates in Serbanescu et al., 2009. FINAL REPORT 89 higher level of care. Components of the basic model of prenatal care include screening for and treating lo- cally endemic illnesses in accordance with national protocols (e.g., screening for syphilis); education of the woman and her family members on signs of preg- nancy complications requiring medical attention; and counseling on nutrition, birth preparedness, breast- feeding, and post-partum family planning. Under the 1997 Georgian Law on Health Care, Article 132, maternity care is currently covered through man- datory medical insurance (Government of Georgia, 1997). In accordance with the new WHO protocol, the basic-benefit package for obstetric care covers four free-of-charge prenatal visits per pregnancy (at 13, 20–22, 30–32 and 36 weeks of pregnancy). The pro- tocol for each visit includes oral history, clinical exami- nation, laboratory tests, ultrasound examination (at 20-22 weeks), screening (for syphilis, Rh isoimmuniza- tion, and HIV), and counseling. Women who are identified as having risk factors dur- ing the first visit are referred for more specialized care and/or further testing. A free-of-charge delivery voucher in the amount of 400 Georgian Lari (GEL), or about USD 228.00, is provided to socially vulnerable populations; vouchers for other pregnant women cov- er only 200 GEL (about USD 114.00) toward delivery costs (CoReform Project, 2005). Women seeking deliv- ery vouchers are required to be enrolled at a Women’s Consultation Center and must complete the minimum of four prenatal visits. Although recommended by the WHO model, post- partum care is not covered under the state program. Once the health reform process is complete, it is an- ticipated that family practitioners will provide most 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) AL MD RO RU UA AM AZ GE KZ KG TM UZ 30 25 20 15 10 5 0 Percentage of Women Receiving No Prenatal Care Live Births in the Last 5 Years: Eastern Europe and Eurasia Figure 6.2.1 3 Eastern Europe Caucasus Central Asia Source: Most recent RHS or DHS survey in AL=Albania , 2008; MD=Moldova, 2005; RO=Romania 2004; RU=Russia 1999; UA=Ukraine 2007; AM=Armenia 2005; AZ=Azerbaijan 2006; GE=Georgia 2010; KZ=Kazakhstan, 1999; KG=Kyrgyz Republic, 1997 TM=Turkmenistan, 2000; UZ=Uzbekistan., 1996 1 7 4 1 6 22 2 5 3 2 5 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Percentage of Women Receiving No Prenatal Care by Selected Characteristics—Births in 2005–2010 Figure 6.2.2 Percentage of Births 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Total Residence Urban Rural Education (yrs) <11 11 Complete >11 Age Group <20 20-34 35-44 Ethnic bGroup Georgian Azeri Armenian Other 2 1 3 6 2 0.3 4 1 3 1 6 4 12 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 90 postpartum care and will refer mothers with any signs of complications to specialized care. Table 6.2.1 presents the percentage of births (live births and stillbirths) from January 2005 to date of interview for which the respondents reported that they received prenatal care. Although differences in prenatal care may exist between women having still- births and those having live births, the small number of stillbirths reported for the period under considera- tion does not allow the separate study of pregnancies ended in stillbirth. Use of prenatal care was almost universal: 98% of pregnant women received at least one prenatal exam- ination. The percentage of pregnant women receiving no prenatal care ranged from less than one percent in Imereti and Tbilisi to 7% in the Kakheti region. The probability of not receiving prenatal care was high- est among rural residents, women whose maternal age was less than 20 years at time of delivery (4%), women with less than a secondary complete educa- tion (6%), women living in households with the lowest wealth quintile (6%), and those for whom the child’s birth order was third or higher (5%). Women with a minority ethnic background were more likely to re- port that they received no prenatal care, compared to Georgian women (Figure 6.2.2). Prenatal care coverage has improved significantly since 1999. According to the results of the 1999 Re- productive Health Survey, 9% of mothers who gave birth in the 5 years prior to the survey received no prenatal care, compared to only 5% in 2005 and 2% in 2010 (Figure 6.2.3). Compared to 1999, the greatest reductions in the number of women receiving no prenatal care in 2010 were in rural areas (from 14% to 3%), among women with less than complete secondary education (from Percentage of Women Receiving No Prenatal Care by Residence Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.2.3 Total Urban 15 10 5 0 Rural 1999 2005 2010 Percentage of Births Percentage of Women Receiving No Prenatal Care by Selected Characteristics Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.2.4 Percentage of Births <11 11+ 30 25 20 15 10 5 0 Georgian Armenian11 Complete 1999 2005 2010 Azeri Education Ethnicity 30 14 6 12 6 2 3 2 0.3 6 4 1 28 12 6 10 5 4 FINAL REPORT 91 30% to 6%), and among Azeri women (from 28% to 4%) (Figures 6.2.3 and 6.2.4). The majority (90%) of respondents initiated prena- tal care during the first trimester of their pregnancy (Table 6.2.1). Urban women were more likely than rural women to initiate prenatal care during the first trimester (93% vs. 86%), as were women living in the regions of Tbilisi (94%) and Adjara (93%), compared to those living in the other regions of the country. Re- ceipt of prenatal care in the first trimester increased directly with maternal education and the wealth quin- tile of the households. Overall, initiation of prenatal care in the first trimester increased from 63% in 1999 to 71% in 2005, to 90% in 2010 and the improvement was consistent across all subgroups (Figure 6.2.5). Overall, the majority (90%) of pregnant women re- ceived four or more prenatal care examinations, in- cluding 12% who received 10 or more visits (Table 6.2.1). On average, pregnant women received 6.5 prenatal care visits (not shown). Completion of four or more prenatal visits was more common in urban areas than in rural areas (95% vs. 86%) and in the regions of Shida-Kartli (98%), Tbilisi (96%) and Imereti (96%), and least common in the regions of Racha-Svaneti (78%) and Kvemo Kartli (80%) (Figure 6.2.6). The mean num- ber of prenatal care visits also varied by region (from over seven visits per pregnancy in Tbilisi and Imereti to five in Samtskhe-Javakheti and Guria, but no region reported less than five visits, on average (data not shown). 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Initiation of Prenatal Care in the First Trimester by Selected Characteristics Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.2.5 0% 20% 40% 60% 80% 100% Total Residence Urban Rural Education (yrs) <11 11 Complete >11 Ethnic bGroup Georgian Azeri Armenian 2010 2005 1999 * Abkhazia: Autonomous region not under goverment control Completion of at Least 4 Care Visits by Region Births in 2000-2005 Figure 6.2.6 Infant Mortality Rate (Per 1.000 Live Births) 30+ 25-29 20-24 15-19 <15 * REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 92 As expected, the percentage of pregnant women re- ceiving four or more prenatal examinations increased as their educational attainment and socioeconomic status increased, from a low 79% among women with less than a full secondary education to 95% among women with high education, and from 78% among women within the lowest wealth quintile to 97% among women within the highest wealth quintile. The percentage of pregnant women receiving four or more prenatal examinations did not vary significantly with maternal age, but was inversely related to the birth order, from a high of 94% among first order births to a low of 80% among third or higher order births. Minor- ity women were less likely to have had four or more prenatal examinations than Georgian women. The percentage of pregnancies receiving 10 or more prenatal examinations was the highest in Tbilisi and Imereti and increased as the educational attainment and socioeconomic status of the expectant mothers increased. All prenatal care indicators improved between 1999 and 2010. The overall use of prenatal care and the ear- ly initiation of care in the first trimester increased from 91% to 98% and from 63% to 90%, respectively, and the percentage of pregnant women receiving four or more examinations increased from 76% to 90%. Con- trary to previous surveys, the improvements included some of the most disadvantaged groups of women, rural residents, those with less than a complete sec- ondary education, and residents of the southern re- gions (Figures 6.2.7 and 6.2.8). The improvements in antenatal care are likely due to a shift in the propor- tion of pregnant women who reported no or low at- tendance in 1999 and 2005, toward more in the cat- 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Completion of 4+ Prenatal Care Visits By Residence and Education Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.2.7 0% 20% 40% 60% 80% 100% Total Residence Urban Rural Education (yrs) <11 11 Complete >11 2010 2005 1999 90% 76% 76% 95% 88% 86% 86% 65% 67% 87% 52% 55% 71% 67% 95% 85% 86% 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Completion of at Least 4 Prenatal Care Visits by Region Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.2.8 0% 20% 40% 60% 80% 100% Total Tbilisi Imereti North-East South West 2010 2005 1999 FINAL REPORT 93 egories of 4-6 and 7-9 visits in 2010. The proportion at 1-3 months fell in 2010 in favor of increases for more visits (Figure 6.2.9). As shown in Figure 6.2.10, one in two women with births in 2005-2010 received most of their prenatal care from women’s consultation clinics (49%); 44% re- ceived their care from regional or city maternity hos- pitals. Only 7% received care from primary health care or family medicine centers, while 1% received care from other sources. As in the previous surveys, the 2010 study included ad- ditional questions to assess adequacy of prenatal care content. Specifically, respondents were asked about what types of counseling they received and what as- sessments were performed during the prenatal visits. Dissemination of health messages is an important component of prenatal care visits. In the absence of routine preconception care, the first prenatal visit is a critical opportunity to screen women for behavio- ral risk factors (e.g., tobacco and alcohol use), medical and genetic risks, and occupational risks, as well as to provide comprehensive counseling. Counseling should cover maternal behaviors and exposures that may af- fect the health of the fetus, nutrition, the importance of rest, and early signs and symptoms of pregnancy complications. In addition, as the time of delivery ap- proaches, counseling should prepare women for what they will face when giving birth and provide accurate information regarding labor, delivery, and techniques to reduce pain and anxiety during labor. Also, coun- seling about breastfeeding and family planning after birth should be initiated during the prenatal period Place of Most Prenatal Care Visits Births in the Last 5 Years: GERHS10 Figure 6.2.10 Women’s Consult Clinic Regional Hospital City Hospital Primary Care Center Other 49% 17% 27% 7% 1% Number of Prenatal Care Visits Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.2.9 0 1-3 4-6 7-9 1999 2005 2010 10 or more Unknown 9% 4% 2% 15% 19% 7% 39% 38% 54% 20% 18% 24% 16% 19% 12% 1% 1% 1% 9% 4% 2% 9% 4% 2% REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 94 and reinforced during postpartum care. As shown in Table 6.2.2, 89% of women who attended prenatal care clinics received some counseling about nutrition during pregnancy; 81% received information about delivery; and 79% received information about breastfeeding. Two in 3 women received informa- tion on potential complications during pregnancy and their early signs; 63% of pregnant women and 60%, respectively, received information on the negative ef- fects of smoking and alcohol use during pregnancy; 59% of women received information about postnatal care; and a low 39% received information about fam- ily planning after birth. Maternal characteristics that appear to be associated with lower levels of coun- seling for most of the topics include rural residence, residence in Samtskhe-Javakheti and Samegrelo, less than complete secondary education, and membership in the lowest wealth quintile. The proportion of wom- en receiving information during prenatal care visits was directly correlated with the number of prenatal visits (see bottom of Table 6.2.2). Compared to 1999 and 2005, the overall level of coun- seling improved in 2010 for all topics (Figure 6.2.11). The greatest improvement occurred in the proportion of women who received counseling on family plan- ning after birth —which almost doubled from 20% in 1990 to 39% in 2010—and in the proportion of wom- en who received information about postnatal care— which increased from 37% to 59%. The proportion of women who were counseled about warning signs of pregnancy complication increased from 48% to 66%. The percentages for smoking and alcohol also rose. But despite all these substantial increases, these top- ics still lag behind the 2010 levels for the other three topics in Figure 6.2.11. In addition to counseling, prenatal care should include a careful medical history of the woman and her family, to include information about risk factors and genetic disorders; a detailed obstetrical history; clinical and obstetrical examination; measurements of maternal weight, height, and blood pressure; urine tests; basic blood tests; an ultrasound exam (during the second visit); and tests for various types of infection (e.g., syphilis and HIV). Tables 6.2.3 and 6.2.4 show the per- centage of women receiving prenatal care who un- derwent selected examinations and measurements. Overall, almost all women (92%–99%) had at least one routine measurement of weight and height, blood pressure, urine tests, and basic blood tests. About 65% had an HIV test during the prenatal period, com- pared to 46% in 2005 (a 50% increase); and 97% had at least one ultrasound exam. Compared to previous surveys, the 2010 study found that not only did the practice of measurements and lab work during pregnancy improve overall, but also that it improved in the most disadvantaged groups. Contrary to previous surveys, the receipt of measure- ments and tests during prenatal care in 2010 varied little by maternal characteristics. The only notable exception remains HIV screening during pregnancy, which was much more likely to be performed in urban areas than in rural areas (75% vs. 55%). It also varied by region (with the lowest coverage in Samtskhe-Ja- vakheti and Adjara), was directly correlated with edu- cation and socio-economic status, and was the least likely to be performed when most of the prenatal care was obtained in a primary care or family medicine center. More than three-fourths of women (77%) reported receiving their first ultrasound exam during the first Type of Counseling Received during Prenatal Care Births in the 5 Years Prior to GERHS: 1999, 2005 and 2010 Figure 6.2.11 Nutrition 1999 2005 2010 9% 4% 2% 9% 4% 2% Delivery Breast- feeding Pregnancy Complications Effects of Smoking Effects of Alcohol Postnatal Care Family Palnning 81% 77% 89% 71% 69% 81% 73% 67% 79% 48% 56% 66% 54% 50% 63% 53% 49% 60% 37% 42% 59% 20% 26% 39% FINAL REPORT 95 trimester of pregnancy, a substantial increase from 2005, when only 44% of women received the test then. This finding suggests that ultrasound exami- nation is now increasingly used as part of the initial pregnancy assessment—to confirm pregnancy, ensure that it is neither molar nor ectopic, assess gestational age, and determine the due date. 6.3 Intrapartum Care The vast majority of births since January 2005 were delivered in health care facilities; only 2% of the births were delivered elsewhere (Table 6.3.1). Essentially all births in urban areas were delivered in medical fa- cilities. The percentage of home births was uniformly very low, with the exception of Kakheti region (8%), women with less than complete secondary education (6%) and those residing in households within the low- est wealth quintile (4%), and women of Azeri or other ethnic group background (5% and 9%, respectively). Overall, between the 2005 and 2010 surveys, the percentage of births attended at home dropped pre- cipitously (from about 8% to 2%). The largest declines were noticeable in regions with high home delivery rates (Figures 6.3.1 and 6.3.2). Deliveries at home among residents of Kakheti fell by 73% (from 30% to 8%). Home deliveries in Kvemo-Kartli and Guria, where in 2005 they represented 15% and 12% of all births, were almost eliminated. Steep declines were also reported among women of a minority ethnic group. Among Azeri women, the decline in home deliveries was remarkable, from 40% in 2005 to 5% in 2010. Table 6.3.2 shows the average amount of time spent in a medical facility prior to the delivery, and also the length of stay after the delivery. The average time spent prior to delivery was about 4 hours and varied little by the characteristics of the mothers or by the type of delivery. Considering that the average duration of labor is between ten hours for nulliparous women and six hours for multiparous women, most women were admitted for delivery around or right after the onset of labor. Standards of care in Georgia stipulate 4 days of post- partum hospital care after uncomplicated deliveries, 5 days after pregnancy or delivery complications, and 6 days after deliveries by cesarean section. The 2010 data show that 56% of women who gave birth in a medical facility were discharged in the first 4 days after delivery, while 25% were discharged after 5 days and 15% after 6 or 7 days. A small percentage of women (4%) were discharged eight or more days after delivery (Table 6.3.2). Hospital stays of 6 days or more were experienced by almost one in two (48%) of women who delivered by cesarean section and 29% of those who had pregnancy complications. Among the births that took place in a medical facil- ity, 24% were delivered by cesarean section, ranging from a high of 33% in the region of Samegrelo to a low of 9% in the region of Samtskhe-Javakheti (Ta- ble 6.3.3 and Figure 6.3.3). As in many countries, the probability of delivering by cesarean section increases with maternal age, educational attainment, and socio- economic status. Women who reported complications during pregnancy were significantly more likely to deliver by cesarean section than were women with- out complications: 36% vs. 22%. Forty-one percent of women who reported being in labor for more than 12 hours had delivered by C-section, compared to only 8% of women who were in labor for shorter durations. Respondents were asked to identify the most impor- tant reason why they had delivered by cesarean sec- tion (Figure 6.3.4). The most frequent reasons given by the respondents included a previous C-section Percentage of Home Deliveries by Region Births in the 5 Years Prior to GERHS: 2005 and 2010 Figure 6.3.1 2005 2010 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 30% 8% 0% 0% 3% 0% 15% 1% 4% 0% 9% 2% 12% 0% 0% 1% 2% 0% 3% 0% 9% 0% REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 96 (20%), fetal malpresentation (17%), cesarean section performed on request (16%), fetal distress (13%); pro- longed labor (11%); fetopelvic disproportion (10%); and severe bleeding (2%); 11% reported that they received a cesarean section due to “other” factors. According to the Georgian Obstetrics and Gynecol- ogy Association, patient request of cesarean section delivery is not considered a medical indication. Com- pared to the 1999 survey, the prevalence of cesarean deliveries more than tripled in every region; the great- est percentage increase was in the North-East region (5 times higher prevalence in 2010 than in 1999) and in Imereti (4 times higher prevalence in 2010 than in 1999) (Figure 6.3.5). Most of these increases are at- tributable to the adoption of more inclusive indica- tions for cesarean delivery into clinical practice. In Georgia, almost all deliveries (88%) assisted by skilled birth attendants are performed for a fee, which varies by type of facility and type of delivery (Ta- ble 6.3.4). At the time of the survey, mean delivery charges were 453 GEL (about USD 260.00). Reported delivery payments were lower among rural women than urban women, and among abortions performed outside of Tbilisi. Fees increased directly with educa- tion and SES (wealth quintile). The amount paid for a delivery ranged from no payment to over 600 GEL. Only 12% of deliveries incurred no charge while 28% required payments of 600 or more Lari; deliveries by C-section were 1.7 times more expensive than vaginal deliveries and more than half required payments of 600 or more Lari. 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Percentage of Home Deliveries, by Ethnic Group Births in the 5 Years Prior to GERHS: 1999, 2005 and 2010 Figure 6.3.2 0% 10% 20% 30% 40% 50% Overall Georgian Armenian Azeri Other 1999 2005 2010 * Abkhazia: Autonomous region not under goverment control Percentage of Caesarean Deliveries by Region - Births in 2000–2005 Figure 6.3.3 % Births with Caesarean Delivery <15 15-19 20-24 25-29 30+ * FINAL REPORT 97 6.4 Postpartum Care Post-delivery assessments of the health of both mother and infant are important, as is comprehensive counseling. Care of a new mother after delivery helps ensure that she is in good physical health and is pre- pared to care for her infant. The postpartum period is a critical time for health care providers to evalu- ate the physical and psychological health of the new mother and her infant, to detect and treat postpartum complications, and to provide counseling and support needed to address any specific problems related to care of the child (WHO, 2002). As discussed above, the WHO postpartum four-visit model is not currently included in the state program. However, because the majority of deliveries take place in maternity hospi- tals, some immediate postpartum care to the mother and her newborn is provided by attending physicians and nurses during the post-birth hospital stay (4–6 days). Any postpartum care that is provided after the hospital discharge, tends to be focused on health and development of the newborn; maternal health usually receives little follow-up (CoReform Project, 2005) As shown in Table 6.4.1, only 23% of mothers received postpartum care after they left the hospital. Although this is an improvement over the 1999 level, there was almost no change compared to the 2005 level. Fur- ther, Georgia ranks last in the region with regard to the percentage of women receiving such care, which highlights the need to include postpartum coverage under the state maternal and child care program (Fig- ure 6.4.1). Levels of postpartum care ranged from a low of 16% in the regions of Guria, Samegrelo, and Shida Kartli to a high of 32% in the region of Mtskheta-Mtianeti (Fig- ure 6.4.2). Rates increased with educational attain- ment and wealth quintile but were especially elevated among women who experienced postpartum com- plications compared to those without complications: 44% vs. 21%. In 2010 about three out of four wom- en who received postpartum care (73%–79%) were counseled at least once on breastfeeding, breast care, child care, immunization, and nutrition (Figure 6.4.3). Notably, only 43% of the women received counseling on family planning. Compared to 1999, rates of coun- Main Reason for Caesarean Delivery - Births in 2005–2010Figure 6.3.4 On Request 16% Malpresentation 17% Previous C-Section 20% Obstetric hemorrhage 2% Baby too big (CPD) 10% Prolonged labor 11% Other 11% Baby started to suffer 13% Percentage of Caesarean Deliveries by Region Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.3.5 Total Imereti North-East WestTbilisi 1999 2005 2010 South 6% 13% 24% 7% 14% 23% 8% 13% 33% 8% 14% 20% 4% 11% 14% 9% 12% 30% REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 98 seling on all topics unfortunately fell in both 2005 and 2010. Only family planning counseling rates increased, from 20% in 1999, to 31% in 2005 and 43% in 2010. However even the 43% remains less than half of the 23% of mothers who received any postpartum care at all. WHO recommends that the first postpartum visit take place within one week after birth (WHO, 2002). As shown in Table 6.4.2, 31% of the subgroup that received any postpartum care reported making the postpartum visit during the first six days after delivery, while an additional 42% made their initial visit one to two weeks after delivery, and 27% made their initial visit more than two weeks after delivery. The survey asked each mother if a health professional checked the baby’s health and, if so, how soon after delivery the examination was made. As shown in Table 6.4.3, overall, 84% of newborns received a well-baby checkup. Well-baby care was higher among urban than rural residents (90% vs. 79%) and ranged from lows of 72%-75% in the regions of Racha-Svaneti, Samtskhe-Javakheti, and Kvemo Kartli to a high of 92% in the region of Tbilisi (Figure 6.4.4). As with other in- dicators discussed in this chapter, the likelihood of receiving well-baby care increases as the educational attainment and socioeconomic status of the mother increase. Among the respondents who took their newborn to a health professional to be examined, 22% took their infant during the first six days follow- ing delivery, while 53% made their initial visit one to two weeks after delivery. An additional 24% took their newborn for an examination more than two weeks following delivery. Percentage of Mothers Receiving Postpartum Care Births in the 5 Years Prior to the Survey Selected Countries in Eastern Europe and Caucasus Figure 6.4.1 Moldova 100 80 60 40 20 0 Romania Ukraine Azerbaijan Georgia 2005 Georgia 2010 74 38 58 25 11 22 23 Georgia 1999 Eastern Europe Caucasus * Abkhazia: Autonomous region not under goverment control Percentage of Mothers Receiving Postpartum Care by Region—Births in 2005–2010 Figure 6.4.2 % Mothers who Received Postpartum Care <20 20-24 25-29 30+ * FINAL REPORT 99 As shown in Table 6.4.4, virtually all (97%) babies born alive in 2005–2010 were registered, according to the mother. The majority of mothers registered their births during the first six days following delivery (81%), while an additional 16% did so one to four weeks af- ter delivery. Urban women were more likely than rural women to register their births soon after delivery. 6.5 Smoking and Drinking During Pregnancy Use of tobacco and alcohol during pregnancy are major risk factors for pregnancy outcomes. Maternal smoking is linked to low birth weight, preterm deliv- eries, sudden infant death syndrome, and respiratory problems in the newborn (DiFranza and Lew, 1996). Research also suggests that woman who drink alcohol while pregnant are more likely to have miscarriages, stillbirths, and premature deliveries (Wilsnack SC et al., 1984; Kesmodel U et al., 2002). No amount of alco- hol is considered safe to drink during pregnancy, and there is a linear relationship between the quantity of alcohol consumed and the chances of birth defects (fetal alcohol syndrome) or physical and mental devel- opmental problems. Respondents who gave birth during the five years pri- or to the 2010 survey were asked “On average, how many cigarettes did you smoke per day after you were pregnant?” and “How many times per week did you drink alcoholic beverages during the pregnancy?” As shown in Table 6.5, only 4.2% of the women were smokers at the time that they discovered they were pregnant, and less than half of them (1.8%) contin- ued to smoke after they found out they were preg- nant. Smoking during pregnancy was highest in Tbilisi (4.6%), among women whose households were within the highest wealth quintile (3.4%), and among women of “other” ethnicity (5.4%). Most of the mothers who smoked during pregnancy smoked 1-4 cigarettes per day. Only 1.1% of women reported drinking during * Abkhazia: Autonomous region not under goverment control Completion of Well-Baby Check-Ups by Region—Live Births in 2005–2010 Figure 6.4.4 % Babies with Well-Baby Visits <75 75-84 85-89 90+ * Type of Postpartum Counseling Among Women Who Received Postpartum Care Births in the 5 Years Prior to GERHS: 1999, 2005 and 2010 Figure 6.4.3 1999 2005 2010 Breast- feeding Child care Inmunization Family Planning Breast Care Nutrition 88% 79% 79% 88% 79% 75% 89% 76% 78% 90% 65% 76% 89% 72% 73% 20% 31% 43% REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 100 pregnancy; most of these women (61%) consumed al- cohol less than once per week (data not shown). 6.6 Pregnancy and Postpartum Complications As shown previously in Table 5.2.3, routine meas- urement of blood pressure was almost always (96%) reported as being part of the risk assessment dur- ing prenatal visits. Of the women whose blood pres- sure was measured, 10% were identified as having high blood pressure (Table 6.6.1). The prevalence of reported high blood pressure during pregnancy was highest among women whose maternal age at deliv- ery was 35–44 years (21%). Overall, 1% of the women were hospitalized due to high blood pressure; higher hospitalization levels were reported by women resid- ing in Kakheti (2%) and those who had most of their prenatal care visits in city maternity hospitals (2%). Nearly 16% of women with births in the last five years reported pregnancy complications requiring medi- cal attention (Table 6.6.2). The conditions mentioned most often were risk of preterm delivery (8%), anemia related to pregnancy (4%), water retention or edema (3%), high blood pressure (3%), and bleeding either early or late (3%). Pregnancy complications requir- ing medical attention were more prevalent among women living in Mskheta-Mtianeti (24%), Shida Kar- tli (22%) and Imereti (21%) and women whose age at delivery was 35–44 years (20%). Almost one in three women with pregnancy complications reported that they had been hospitalized for these conditions (data not shown). Postpartum complications reported by women who gave birth in the five years prior to the survey are shown in Table 6.6.3. Overall, 11% of the women re- ported at least one postpartum complication. The complications mentioned most often were severe bleeding, painful uterus, high fever, breast infection, infectious vaginal discharge, painful urination, and in- fection of the surgical wound. 6.7 Poor Birth Outcomes As in the previous rounds, the 2010 study collected a complete pregnancy history, asking each woman about her lifetime pregnancy experiences, including information about pregnancies resulting in fetal death. Multiple definitions are in use in different countries based on different parameters (i.e. gestational age or weight at birth) and standards of viability. For interna- tional comparability, the 2010 survey used the WHO recommendations and included in the calculation of stillbirth rate all infants born dead after 28 completed weeks of gestation (roughly weighing 1,000 grams or more at birth). Thus, stillbirth rate data presented here refer to late fetal deaths, i.e. the number of ba- bies born dead after 28 weeks of gestation per 1,000 total births. Of all births that occurred during the five years prior to the survey, 8 per 1,000 (95%CI=3.1-13 per 1,000) were stillbirths (Table 6.7). This rate is low- er than the rate of 13.4 per 1,000 reported by gov- ernmental sources for the 2005-2010 periods (WHO, 2011a, 2011b). Stillbirth rates were twice as high in urban areas as in rural areas and were the highest in Mtskheta-Mtian- eti (21.8 per 1,000), followed by Kakheti, Tbilisi, and Racha-Svaneti. The stillbirth rate was highest among woman who did not receive any prenatal care (50.0), women who suffered complications during their preg- nancies (33.5), and women with prolonged labor (29.6). Overall, the low birth weight rate, which is the per- centage of live births with birth weight under 2,500 grams, was 4.2% among infants born alive. Slightly higher rates were reported by women living in the regions of Mtskheta-Mtianeti (7.6%), women with a 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Percentage of Children Ever Breastfed Live Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.8.1 60% 70% 80% 90% 100% Total Rural Urban 1999 2005 2010 87% 88% 87% 89% 89% 88% 84% 87% 87% FINAL REPORT 101 maternal age of 35-44 years (11.1%), women who de- livered by cesarean section (7.7%), and women who experienced complications during their pregnancies (10.9%). The reported prematurity rate (percentage of live births delivered before 37 weeks of gestation) for the same time period was 3.8%. Higher prematurity rates were associated with the same maternal and preg- nancy characteristics identified for higher risk of low birth weight. 6.8 Breastfeeding WHO recommends that all infants are fed exclusively on breast milk from birth to 6 months of age, followed by continued breastfeeding, together with appropri- ate complementary feeding, for up to two years of age or beyond (WHO, 2002). An infant is considered to be “exclusively” breastfed if he or she receives only breast milk and is “predominately” breastfed if he or she receives breast milk accompanied by water, wa- ter-based drinks, fruit juice, or other liquids (except non-human milk and food-based fluids) (WHO, 1991). Children with exclusive or predominant breastfeeding are considered to be “fully” breastfed. Table 6.8.1 and Figure 6.8.1 show that, 87% of infants born since January, 2005 were breastfed. This rate is essentially unchanged from the 1999 and 2005 sur- veys. Differences in breastfeeding by residence, re- gion, maternal age, educational attainments, and birth order were slight, although Georgian women re- ported lower rates of ever-breastfeeding than women other ethnicities. Among babies who weighted less than 2,500 grams at birth, only 64% were reported to have been breastfed (see bottom of Table 6.8.1). Months Average Duration of Breastfeeding (in Months) by Type of Breastfeeding Live Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.8.3 Exclusive Breastfeeding Full Breastfeeding 14 12 10 8 6 4 2 0 Any Breastfeeding 1999 2005 2010 1.5 1.8 3.0 3.7 3.7 4.1 10.6 10.1 12.2 1999 2005 2010 Initiation of Breastfeeding Following Birth (in Hours) Live Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.8.2 0% 20% 40% 60% 80% 100% 5 10 20 28 48 55 37 26 13 30 15 11 <1 hour 1-23 hours 24-47 hours 48 or more hours REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 102 According to WHO recommendations, early breast- feeding (i.e., within the first hour of life) should be encouraged after all spontaneous deliveries. How- ever, only 20% of infants were breastfed within the first hour following birth. The percentage of infants that were breastfed within the first hour ranges from a high 33% in Samtstkhe-Javakheti and Mtskheta-Mti- aneti to a low of 9% in Adjara. An additional 55% of infants were breastfed within 1-23 hours after birth. Thus, overall, 75% of the infants were breastfed with- in the first day. Among infants delivered by Cesarean section, only 50% were breastfed within the first day, while 25% were breastfed for the first time within 48 hours, and another 25% later. Since the 1999 survey, the proportion of babies who were breastfed within the first hour after birth increased by 4 times (from 5% in 1999 to 10% in 2005, and 20% in 2010), while the proportion of those who received breast milk 1-23 hours after birth doubled, from 28% to 55% (Figure 6.8.2). The proportion of children under 5 years old still be- ing breastfed at the time of the survey was calculated by months of age (0-59 months); the denominator included all live births in the 5 years preceding the survey, regardless of survival. Those proportions were summed to calculate the mean duration of breast- feeding. This method is known as the “current status mean” method (WHO, 1991). Durations of exclusive and full breastfeeding were calculated in the same way. Table 6.8.2 and Figure 6.8.3 show data on the mean duration of breastfeeding. The mean duration of any breastfeeding was 12.2 months, 2 months longer than the 10.1 months recorded in the 2005 survey. The mean duration of full breastfeeding (either exclusive breastfeeding or predominately breastfeeding) was 4.1 months, longer than the 3.7 months documented in the 1999 and 2005 surveys. Perhaps the most important gain was in the duration of exclusive breastfeeding (only breast milk), which doubled from the level documented in the 1999 sur- vey (from 1.5 to 3.0 months). Breastfeeding increases especially as birth order in- creases: patterns for “any breastfeeding” were similar across most categories shown in Table 6.8.2, except- ing birth order. Smaller differences appeared by resi- dence and wealth quintile. 6.9 Infant and Child Mortality The reduction of mortality among children under five by two-thirds between 1990 and 2015 is centrally for- mulated in the Millennium Development Goal 4 (MDG 4). In view of the short time left to meet the goal, ef- forts must be scaled up worldwide to save the lives of children in their first 5 years of life; therefore demand is increasing for reliable national data on under-5 mor- tality levels and trends to guide national action priori- ties and further research. Globally, average infant mortality rates have fallen steadily over recent years, from 65 per 1,000 in 1990 to 62 per 1,000 in 2000 and 42 per 1,000 in 2009 (UNICEF, 2001 and 2011). Consequently, rates of mor- tality among all children under five have fallen from 95 per 1,000 live births in 1990 to 84 per 1,000 live births in 2000 and 79 per 1,000 live births in 2004 and 60 per 1,000 live births in 2009 (UNICEF, 2001 and 2011). Yet, 8.8 million children still die each year, in- cluding about 5.6 million infants who die before they are one year old; 99% of these deaths occur in low- and middle-income countries. A substantial propor- 1995 1997 1999 2001 2003 2005 2009 50 40 30 20 10 0 Infant Deaths per 1.000 Live Births Infant Mortality in Georgia Official Estimates and Survey Estimates for 1995–2009 Figure 6.9.1 2007 SDS MoLHSA GERHS YEAR 28.2 24.6 14.9 14.1 Source: Revised SDS estimates available at http://statistics.ge; Georgian MoLHSA estimates in L. Sakvarelidze, 2010 FINAL REPORT 103 tion of infant and child mortality is due to newborn mortality; in 2009, the neonatal death rate was 24 per 1,000 live births, representing 39% of all deaths in children under 5 years of age and more than half of infant mortality. The major direct causes of neonatal deaths globally are infections (36%), premature birth (28%), and asphyxia (23%) (Lawn et al., 2005). Among children under five, 68% of deaths are attributable to infectious diseases, including pneumonia (18%), diar- rhea (15%), malaria (8%), neonatal sepsis (6%), AIDS (2%). Preterm birth complications (12%) and asphyxia at birth (9%) were other major causes of death among children under five (Black et al., 2010). As in the previous surveys, the 2010 data were used to calculate mortality levels among respondents’ chil- dren, specifically, infant mortality (i.e., deaths before the first birthday), child mortality (i.e., deaths be- tween 12 and 59 completed months of age), and un- der-5 mortality (i.e., deaths before the fifth birthday). Infant mortality was further divided into two periods: neonatal (0–28 days) and post-neonatal (29 days to 11 completed months). The survey estimated levels and trends in infant and child mortality based on birth histories and child survival information. The question- naire included a series of questions for each live birth: date of birth, sex of child, survival status, and for chil- dren who had died, age at death. This information al- lows a direct calculation of infant and child mortality rates for precise periods of time, by means of life ta- bles. Survey data-based mortality estimates should be viewed as minimum estimates because they may be subject to underreporting. For example, information on a deceased child whose mother has also died will simply not be gathered; some mothers may not ac- knowledge a child who died shortly after birth; others may not recall the exact date of birth or may be unwill- ing or unable to recall at what age a child died. Despite these limitations, population-based survey estimates of infant and child mortality are quite robust and have proved instrumental in countries where official birth and death rates are incomplete or inaccurate. Because surveys count events experienced by a randomly se- lected sample, rather than the entire population, the resulting estimates are subject to a certain degree of sampling error (see Appendix B). To adjust for sam- pling error, 95% confidence intervals around survey estimates were calculated; consequently, we can say that the true value of a statistic lies within the bound- aries of the 95% confidence interval. Two different sources of birth and death data exist in Georgia. The SDS collects information from civil regis- tration offices, which are responsible for the issuance of official birth and death certificates to family mem- bers who submit birth or death certificates from medi- cal facilities. The Center for Medical Statistics and In- formation (CMSI) collects aggregated reports of births and deaths from hospitals, maternity centers, and outpatient clinics. These reports are mainly used by the Ministry of Labor, Health and Social Affairs (MoL- HSA) and are not included in the governmental official reports, but they have consistently documented more births and deaths than the SDS reports. Figure 6.9.1 presents various estimates of changes in the infant mortality rate in Georgia, using data from all available surveys and official statistics. The most re- cent available figures for 2009 are in good agreement among all sources (14.1–14.9 deaths per 1,000 live births). The figure includes the three values shown by the triangles for estimates based on the three GERHS surveys. The final points, for 2009, represent the low- est rates since 1990. Infant Mortality Rates Live Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.9.2 Infant Deaths per 1.000 Live Births 1995-1999 GERHS99 60 50 40 30 20 10 0 2000-2004 GERHS05 2005-2009 GERHS10 Survey Period REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 104 The pattern of change is obscured in the official vital records because of substantial underreporting prior to 2002, particularly in the figures published by the national State Department of Statistics (SDS). Start- ing with 2002, the government of Georgia, in collab- oration with UNFPA and other international donors, launched an initiative to improve the vital registration system (WHO and CMSI, 2003). The MoLHSA put forth recommendations for implementation and calculation of child health indicators, revised the format of the medical death certificate, and provided instructions for completing and issuing the certificate (Order Nos. 141 of Oct. 2000 and 94/0 of Dec. 2000). A presiden- tial decree—Decree 31 of December 10, 2002—put forth new rules for birth and death registration (Gov- ernment of Georgia, 2002). Thus, infant mortality trends that are based on official estimates are difficult to interpret because the changes in birth and death registration after 2002 are likely to have improved the completeness and accuracy of official estimates whereas the figures prior to 2002 underestimate the true mortality levels. Table 6.9.1 presents mortality estimates for the 5 year periods prior to the 2010, 2005 and 1999 surveys. For example the estimated infant mortality rate for the period January 2005–December 2009 was 14.1 per 1,000 live births and the child mortality (1-4) rates was 2.3, so these sum to the under-5 mortality rate of16.4 per 1,000. The neonatal mortality rate was estimated at 9.5 per 1,000, while the post-neonatal mortality rate was estimated at 4.5 per 1,000, and these sum to the infant mortality rate of 14.1. Thus, the neona- tal rate is twice as high as the post-neonatal rate and constitutes 67% of the infant mortality rate and 58% of the under-5 mortality rate. This finding is not un- expected: child mortality after the first month of life declines faster than neonatal mortality does; hence, Neonatal Mortality Rates Live Births in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.9.3 Neonatal Deaths per 1.000 Live Births 1995-1999 GERHS99 60 50 40 30 20 10 0 2000-2004 GERHS05 2005-2009 GERHS10 Survey Period Deaths Under Age 5 per 1,000 Live Births Prior to GERHS: 1999, 2005, 2010 Figure 6.9.4 Deaths Under Age 5 per 1.000 Live Births 1995-1999 GERHS99 60 50 40 30 20 10 0 2000-2004 GERHS05 2005-2009 GERHS10 Survey Period FINAL REPORT 105 the actual proportion, or share, of deaths that occur in the first four weeks of life (neonatal period), and par- ticularly in the first seven days (early neonatal period) increase over time (Lawn et al., 2005). A comparison with previous survey estimates shows a significant decline in both the neonatal and post-neo- natal mortality rates, which in turn have significantly lowered the infant and under-5 mortality rates over the past 15 years (Table 6.9.1 and Figures 6.9.2–6.9.4). Neonatal mortality declined from 25 in 1995-1999 to 16.8 in 2000-2004 to 9.5 in 2005-2009. Infant mortal- ity declined from 41.6 in 1995–1999 to 21.1 in 2000– 2004 and 14.1 in 2005–2009. The under-5 mortality rate dropped from 45.3 to 25.0 and 16.4, respectively births—a 64% decline. Thus, according to the survey estimates, Georgia has indeed achieved MDG-4 by 2010 (Figure 6.9.5). Focusing on the 2010 survey results for 2000–2009 in Table 6.9.2, the highest infant and under-5 mortality rates were found among children living in rural areas and those born in households within the lowest SES group. Previous surveys showed that the infant mor- tality rate for babies born to Azeri and Armenian moth- ers was twice that of their Georgian counterparts, but the 2010 data no longer show that gap. At first glance in Figure 6.9.6, both the infant and under-5 mortality rates for ethnic minorities clearly declined between 1999 and 2010 more abruptly than did the rates among Georgian children—from 50.0 deaths per 1,000 [95%CI=30.7-71.2] and 57.0 per 1,000 [95%CI=33.6- 74.2] to 23.5 deaths per 1,000 [95%CI=8.7-38.3] and 26.3 deaths per 1,000 [95%CI=10.5-42.1], respec- tively. However because of fewer deaths among the smaller ethnic groups than among Georgians, the decline for the former did not reach statistical sig- nificance. However, the decline in infant and under-5 mortality rates for Georgian children was significant, from 38.3 deaths per 1,000 [95%CI=31.6-45.0] and 42.4 per 1,000 [95%CI=35.9-49.8] to 23.8 deaths per 1,000 [95%CI=17.8-29.9] and 25.9 deaths per 1,000 [95%CI=19.5-32.1], respectively. Mortality Rates Under Age five in the 5 Years Prior to GERHS: 1999, 2005, 2010 Figure 6.9.5 1995-1999 2000-2004 2005-2009 25.4 16.8 9.5 16.2 4.3 4.5 3.8 4.0 2.3 Under-5 mortality rate 45.3 per 1,000 Under-5 mortality rate 25.0 per 1,000 Under-5 mortality rate 16.4 per 1,000 Neonatal Postneonatal Child 1-4 Years Mortality Rates Under Age 5 by Ethnicity in the 10 Years Prior to GERHS: 1999 and 2010 Figure 6.9.6 Mortality Rates 60 50 40 30 20 10 0 1990-1999 2000-2009 1990-1999 2000-2009 38 42 24 26 24 26 50 57 Georgian Other IMR U5MR REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 106 The lowest infant mortality rates were reported in Ra- cha Svaneti, Tbilisi, and Imereti while the highest rates were reported in Samegrelo and Mtskheta-Mtianeti. Those two regions and Kakheti and Shida Kartli had the highest under-5 mortality rates (Figure 6.9.7). Both infant mortality and under-5 mortality increased sharply with birth order. Specifically, the children at highest risk of dying were those born to women with at least two previous births. Unexpectedly, the under-5 mortality rate is quite el- evated for the birth interval of 24-47 months, which is usually a low risk interval. Gender differentials in mortality rates (see bottom of Table 6.9.2) were obvious in the neonatal and post- neonatal periods, probably because girls have a well- known biological survival advantage soon after birth (Ulizzi and Zonta, 2002). In conclusion, child survival in Georgia improved substantially over the past 15 years, mainly through significant reductions in neonatal and post-neonatal mortality. Given that neonatal deaths continue to ac- count for most of infant mortality and 58% of under-5 deaths in Georgia, further reductions in child mortality will depend heavily on continuing the improvements in survival during the neonatal period. Reductions in neonatal deaths, particularly early neonatal deaths, will rest on the provision of effective, individualized maternal and child care. Early neonatal deaths that occur during the first seven days and account for most of the neonatal deaths can be reduced by preventing birth asphyxia, prematurity, and maternal morbidity during labor and postpartum. Late neonatal deaths, which are mainly due to infections, can be prevented through correct management of neonatal infections by better access to emergency obstetric and neonatal care. Overall, neonatal mortality rates can be lowered by educating women regarding the benefits of spac- ing their births, by ensuring access to family planning services, and by improving maternal nutrition and breastfeeding. * Abkhazia: Autonomous region not under goverment control Infant Mortality Rate (per 1,000) by Region—Live Births in the 10 Years Prior to the Survey Figure 6.9.7 Infant Mortality Rate (per 1.000 Live Births) 30+ 25-29 20-24 15-19 <15 * FINAL REPORT 107 Table 6.2.1 Initiation of Prenatal Care by Pregnancy Trimester and Number of Prenatal Visits by Selected Characteristics Among Births in 2005–2010 Reproductive Health Survey: Georgia, 2010 No. of Ch t i ti Trimester of First Prenatal Visit Number of Prenatal Visits T t l No Visits 1st 2nd 3rd Not Stated No Visits 1–3 4–6 7–9 10+ Not Stated Total 1.6 89.8 7.5 0.3 0.7 1.6 7.3 54.3 23.9 12.0 0.9 100.0 2,617 Residence Urban 0.6 93.1 5.8 0.2 0.2 0.6 4.2 52.3 26.2 16.1 0.7 100.0 1,193 Rural 2.7 86.4 9.2 0.5 1.2 2.7 10.5 56.4 21.5 7.8 1.1 100.0 1,424 No. of CasesCharacteristic Total , Region Kakheti 7.1 79.6 7.8 1.2 4.3 7.1 6.7 60.8 17.3 5.5 2.7 100.0 224 Tbilisi 0.6 93.6 5.4 0.2 0.3 0.6 3.7 50.8 27.1 17.6 0.2 100.0 567 Shida Kartli 0.0 91.4 8.6 0.0 0.0 0.0 2.2 62.7 23.8 11.4 0.0 100.0 168 Kvemo Kartli 4.7 86.4 8.5 0.0 0.4 4.7 14.0 50.8 21.7 7.0 1.9 100.0 234 Samtskhe–Javakheti 0.0 89.8 8.1 1.2 0.8 0.0 18.7 63.8 10.6 6.1 0.8 100.0 214 Adjara 0.5 93.2 5.4 0.0 1.0 0.5 7.8 65.9 17.1 8.3 0.5 100.0 176 Guria 0.0 86.2 13.2 0.0 0.6 0.0 9.4 76.1 8.8 3.8 1.9 100.0 140 Samegrelo 1.4 91.9 5.7 0.5 0.5 1.4 12.0 50.7 26.8 7.7 1.4 100.0 184 Imereti 0.3 90.0 9.5 0.3 0.0 0.3 3.3 45.0 32.2 18.7 0.5 100.0 349 Mtskheta–Mtianeti 2.6 84.3 12.2 0.9 0.0 2.6 10.0 52.4 26.6 7.9 0.4 100.0 200 Racha–Svaneti 1.5 87.2 10.7 0.5 0.0 1.5 20.4 43.9 26.0 8.2 0.0 100.0 161 Age Group (at Birth) < 20 3.8 88.3 5.7 0.0 2.2 3.8 6.0 57.5 24.0 8.3 0.4 100.0 313 20 24 1 1 89 2 8 7 0 4 0 6 1 1 7 5 58 8 22 6 9 3 0 7 100 0 95620–24 1.1 89.2 8.7 0.4 0.6 1.1 7.5 58.8 22.6 9.3 0.7 100.0 956 25–34 1.3 90.9 7.0 0.3 0.5 1.3 7.0 51.1 24.2 15.5 0.9 100.0 1,164 35–44 2.9 88.9 7.2 1.0 0.0 2.9 10.8 45.2 28.3 10.3 2.4 100.0 184 Education Level Secondary incomplete or less 5.8 79.6 11.3 0.2 3.1 5.8 13.9 56.0 18.4 4.9 0.9 100.0 422 Secondary complete 2.0 89.2 8.1 0.5 0.2 2.0 9.7 55.4 20.8 11.2 0.9 100.0 738 Technicum/University 0 3 93 0 6 1 0 3 0 3 0 3 4 3 53 3 26 9 14 4 0 8 100 0 1 457Technicum/University 0.3 93.0 6.1 0.3 0.3 0.3 4.3 53.3 26.9 14.4 0.8 100.0 1,457 Wealth Quintile Lowest 5.9 82.5 11.2 0.3 0.1 5.9 15.1 53.2 17.0 8.2 0.6 100.0 428 Second 1.4 87.6 8.6 0.7 1.8 1.4 10.9 56.0 23.0 7.5 1.3 100.0 628 Middle 1.5 89.4 7.8 0.4 0.9 1.5 6.9 61.2 20.8 8.5 1.1 100.0 587 Fourth 1.2 89.9 7.9 0.2 0.7 1.2 3.9 52.4 26.6 14.6 1.2 100.0 413 Highest 0.0 96.0 4.0 0.1 0.0 0.0 2.6 49.1 29.1 19.0 0.2 100.0 561 Birth OrderBirth Order First birth 0.9 93.3 5.0 0.1 0.7 0.9 4.5 54.0 26.0 14.0 0.7 100.0 1,293 Second birth 1.5 87.3 9.8 0.7 0.7 1.5 8.9 55.7 22.7 10.5 0.7 100.0 937 Third or higher 4.6 83.6 10.7 0.2 0.8 4.6 13.3 52.3 19.3 8.5 1.9 100.0 387 Ethnicity Georgian 0.7 91.5 7.1 0.3 0.3 0.7 5.7 54.5 25.3 13.0 0.8 100.0 2,248 Azeri 6.0 81.7 7.8 0.0 4.5 6.0 15.9 55.6 15.8 4.5 2.2 100.0 145 Armenian 3.6 80.7 11.5 0.9 3.3 3.6 23.7 53.9 11.1 7.3 0.5 100.0 145 Other 12.2 77.1 10.1 0.6 0.0 12.2 9.0 48.9 22.3 7.6 0.0 100.0 79 Baby's Weight at Birth* < 2500 grams 2.8 87.8 8.2 0.0 1.2 2.8 13.8 40.2 18.0 20.5 4.7 100.0 125 >= 2500 grams 1.4 90.1 7.4 0.4 0.7 1.4 7.0 55.2 24.2 11.6 0.7 100.0 2,481 * Excludes 11 births with unknown weight at birth. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 108 Table 6.2.2 Percentage of Births For Which Mothers Received Specific Types of Information During Prenatal Care Visits, Among Births in 2005–2010 with Any Prenatal Care, by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Characteristic Nutrition Delivery Breast- Pregnancy Effects of Effects of Postnatal Family No of CasesCharacteristic Nutrition Delivery feeding g y Complications Smoking Alcohol Care y Planning No. of Cases Total 89.4 81.2 78.6 66.0 62.6 59.6 58.6 39.2 2,575 Residence Urban 92.1 84.7 83.1 70.6 67.9 63.8 63.1 42.1 1,184 Rural 86.6 77.6 73.8 61.2 57.1 55.1 53.8 36.1 1,391 RegionRegion Kakheti 85.7 80.2 74.7 66.7 64.6 64.1 59.1 44.7 211 Tbilisi 91.2 84.3 83.7 68.4 66.1 62.4 60.9 37.3 563 Shida Kartli 93.5 74.1 68.6 64.3 57.3 50.8 54.6 20.0 168 Kvemo Kartli 81.7 79.3 74.8 54.9 56.1 54.1 50.0 33.7 223 Samtskhe–Javakheti 78.9 59.3 61.0 42.7 50.8 49.6 42.3 22.4 214 Adjara 94.6 82.8 78.9 57.4 62.7 57.4 52.0 40.2 175 Guria 87 4 84 9 83 0 71 1 62 9 61 6 62 3 22 6 140Guria 87.4 84.9 83.0 71.1 62.9 61.6 62.3 22.6 140 Samegrelo 93.7 80.1 79.1 67.0 49.0 44.2 55.3 31.6 181 Imereti 90.5 86.4 83.6 80.0 72.6 71.3 71.8 60.0 348 Mtskheta–Mtianeti 89.2 83.0 78.0 68.6 63.7 60.5 57.0 42.2 194 Racha–Svaneti 88.1 83.4 78.2 72.0 55.4 55.4 64.8 43.0 158 Education Level Secondary incomplete or less 82.5 73.5 69.0 60.3 50.8 50.0 50.6 30.9 400 or less Secondary complete 89.3 80.6 80.6 62.8 62.8 59.9 57.6 36.2 724 Technicum/University 91.4 83.5 80.2 69.0 65.7 62.0 61.2 42.8 1,451 Wealth Quintile Lowest 83.6 72.2 72.5 58.4 53.2 52.4 49.3 28.1 410 Second 86.3 78.4 72.2 62.6 58.8 54.3 53.9 39.4 619 Middle 90.0 81.7 77.7 65.6 60.3 58.9 59.4 39.0 579 Fourth 92 7 86 4 84 9 69 6 70 7 66 7 60 8 41 9 406Fourth 92.7 86.4 84.9 69.6 70.7 66.7 60.8 41.9 406 Highest 92.5 84.3 83.6 70.7 67.2 63.6 65.1 43.0 561 Birth Order First birth 89.8 81.3 79.8 67.1 64.6 60.9 58.6 39.2 1,285 Second birth 90.5 82.5 78.4 66.0 61.9 59.3 59.4 38.5 924 Third or higher 85.7 77.5 74.6 61.9 57.1 55.4 56.4 40.5 366 Number of Prenatal Visits*Visits* 1–3 81.6 68.0 67.6 56.7 53.7 49.9 52.1 26.3 223 4–6 87.7 79.2 76.2 63.5 58.5 54.6 55.1 36.1 1,445 7–9 93.2 86.0 83.2 70.6 68.7 67.7 63.8 45.2 604 10+ 95.0 89.5 87.4 75.1 75.1 72.0 68.6 49.3 279 Place of Prenatal Primary care clinic /Fam med center 91.2 81.2 73.1 58.0 56.0 57.1 56.1 43.0 172 /Fam.med.center Women's consultation clinic 90.9 82.8 79.5 68.7 67.2 62.4 60.3 38.9 1,206 Regional maternity/hospital 83.4 76.4 74.9 56.0 51.8 50.5 52.2 35.5 471 City maternity/hospital 90.5 81.4 80.7 69.6 62.9 61.0 60.2 41.3 715 * Excludes 24 births with unknown number of prenatal care visits. † Excludes 11 births with other source of prenatal care. FINAL REPORT 109 Table 6.2.3 Selected Measurements Performed During Prenatal Care Visits by Selected Characteristics Among Births in 2005–2010 with Any Prenatal Care by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Characteristic Basic Blood Test Urine Test Weight Measured Height Measured Blood Pressure Measured HIV Test No. of Cases Total 99.2 99.3 99.0 98.1 96.2 65.1 2,575 Residence Urban 99.3 99.2 99.2 98.6 96.5 74.5 1,184 Rural 99 2 99 3 98 8 97 7 95 8 55 4 1 391Rural 99.2 99.3 98.8 97.7 95.8 55.4 1,391 Region Kakheti 97.5 98.3 98.7 96.6 96.2 58.6 211 Tbilisi 99.4 99.4 99.2 98.5 97.5 78.9 563 Shida Kartli 100.0 100.0 100.0 98.4 94.1 74.6 168 Kvemo Kartli 99.6 99.2 99.2 97.6 97.6 54.9 223 Samtskhe-Javakheti 98.8 98.8 95.5 96.3 92.3 43.9 214 Adjara 99 5 99 5 99 5 97 1 92 2 46 6 175Adjara 99.5 99.5 99.5 97.1 92.2 46.6 175 Guria 99.4 99.4 98.7 99.4 93.7 56.0 140 Samegrelo 99.5 99.5 99.5 99.5 97.1 68.9 181 Imereti 99.2 99.2 98.7 99.0 97.4 70.0 348 Mtskheta-Mtianeti 100.0 100.0 99.1 99.1 96.4 53.4 194 Racha-Svaneti 97.4 97.9 97.4 95.3 95.9 49.2 158 Age Group (at Birth) < 25 98 8 99 0 98 8 97 7 95 7 61 4 1 251< 25 98.8 99.0 98.8 97.7 95.7 61.4 1,251 25–34 99.6 99.5 99.2 98.5 96.3 69.0 1,145 35–44 99.9 99.9 98.3 99.0 98.0 66.4 179 Education Level Secondary incomplete or less 98.2 98.7 98.5 95.5 94.7 46.6 400 Secondary complete 99.6 99.6 99.2 99.0 96.5 60.0 724 Technicum/University 99.4 99.3 99.0 98.4 96.4 72.5 1,451 Wealth QuintileWealth Quintile Lowest 98.4 98.4 98.4 97.2 95.6 54.0 410 Second 99.0 99.4 99.3 97.5 95.2 56.2 619 Middle 99.4 99.4 98.4 98.2 95.9 60.1 579 Fourth 99.5 99.5 99.1 97.9 98.2 67.5 406 Highest 99.5 99.4 99.4 99.2 96.1 80.7 561 Birth Order First birth 99.1 99.2 98.9 98.4 95.7 65.8 1,285First birth 99.1 99.2 98.9 98.4 95.7 65.8 1,285 Second birth 99.4 99.3 99.3 98.6 96.6 65.2 924 Third or higher 99.5 99.5 98.3 96.1 96.7 62.3 366 Number of Prenatal Visits* 1–3 98.4 97.8 97.2 96.0 95.5 47.2 223 4–6 99.0 99.1 98.7 97.7 95.3 63.3 1,445 7–9 99.8 99.8 99.8 99.4 97.4 68.1 604 10+ 99.7 99.7 99.3 98.9 97.9 79.6 27910+ 99.7 99.7 99.3 98.9 97.9 79.6 279 Place of Prenatal Care† Primary care clinic/Fam.med.center 96.5 97.1 97.1 94.7 91.4 49.3 172 Women's consultation clinic 99.5 99.5 99.0 98.7 95.5 68.6 1,206 Regional maternity/hospital 99.6 99.6 99.1 96.7 97.3 50.6 471 City maternity/hospital 99.3 99.3 99.3 98.8 97.7 71.7 715 * Excludes 24 births with unknown number of prenatal care visits. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 110 Table 6.2.4 Use of Ultrasound Exams During Pregnancy and Time of First Exam by Selected Characteristics Among Births in 2005–2010 with Any Prenatal Care Reproductive Health Survey: Georgia, 2010 N f CCh t i ti Had Ultrasound Exam Time of First Ultrasound Exam (in Weeks) T t l % No. of Cases ≤ 13 14–19 20–26 27+ Does Not Remember Total 97.4 2,575 77.2 11.4 8.3 2.2 0.9 100.0 2,489 Residence Urban 98.9 1,184 84.4 9.1 5.3 1.1 0.1 100.0 1,167 Rural 95.7 1,391 69.5 13.8 11.4 3.4 1.8 100.0 1,322 No. of CasesCharacteristic Total Rural 95.7 1,391 69.5 13.8 11.4 3.4 1.8 100.0 1,322 Region Kakheti 92.0 211 77.1 7.3 12.4 1.4 1.8 100.0 194 Tbilisi 99.2 563 88.5 8.5 2.5 0.5 0.0 100.0 558 Shida Kartli 99.5 168 73.4 15.2 10.9 0.5 0.0 100.0 167 Kvemo Kartli 96.7 223 73.9 8.4 12.6 4.2 0.8 100.0 215 Samtskhe–Javakheti 96.3 214 67.9 17.3 11.4 3.0 0.4 100.0 206 Adjara 98.5 175 63.2 16.4 10.4 4.0 6.0 100.0 172Adjara 98.5 175 63.2 16.4 10.4 4.0 6.0 100.0 172 Guria 98.1 140 63.5 22.4 10.9 3.2 0.0 100.0 137 Samegrelo 97.6 181 84.6 7.5 6.5 1.5 0.0 100.0 176 Imereti 96.9 348 73.8 13.8 8.5 3.7 0.3 100.0 337 Mtskheta–Mtianeti 96.4 194 74.0 11.2 12.6 2.3 0.0 100.0 188 Racha–Svaneti 87.6 158 63.9 12.4 20.7 3.0 0.0 100.0 139 Age Group (at Birth) < 25 96.8 1,251 74.7 12.3 9.2 2.4 1.4 100.0 1,205< 25 96.8 1,251 74.7 12.3 9.2 2.4 1.4 100.0 1,205 25–34 98.2 1,145 80.2 10.3 7.3 1.7 0.4 100.0 1,115 35–44 95.6 179 76.2 11.9 7.4 3.8 0.6 100.0 169 Education Level Secondary incomplete or less 92.5 400 68.7 9.7 13.5 2.6 5.5 100.0 367 Secondary complete 97.7 724 69.5 15.1 11.9 3.3 0.2 100.0 702 Technicum/University 98.5 1,451 83.0 10.1 5.2 1.6 0.1 100.0 1,420 Wealth QuintileWealth Quintile Lowest 95.6 410 68.0 14.3 14.2 3.5 0.0 100.0 386 Second 96.1 619 71.1 11.6 11.0 4.4 2.0 100.0 591 Middle 96.6 579 73.8 13.9 7.7 2.2 2.3 100.0 557 Fourth 98.8 406 76.8 13.4 8.2 1.5 0.0 100.0 400 Highest 99.0 561 89.6 6.5 3.6 0.2 0.0 100.0 555 Birth Order First birth 97 6 1 285 81 8 9 4 6 5 1 8 0 5 100 0 1 246First birth 97.6 1,285 81.8 9.4 6.5 1.8 0.5 100.0 1,246 Second birth 97.1 924 73.6 13.9 9.0 2.6 1.0 100.0 891 Third or higher 97.0 366 69.6 12.3 12.9 2.7 2.4 100.0 352 Number of Prenatal Visits* 1–3 92.2 223 47.6 24.0 18.2 9.6 0.6 100.0 200 4–6 97.6 1,445 75.9 11.8 9.5 1.5 1.2 100.0 1,410 7–9 98.2 604 82.5 9.0 5.9 2.0 0.6 100.0 586 10+ 99 3 279 89 5 6 9 2 0 1 6 0 0 100 0 27610+ 99.3 279 89.5 6.9 2.0 1.6 0.0 100.0 276 Place of Prenatal Care† Primary care clinic/Fam.med.center 92.0 172 77.5 11.5 7.3 2.4 1.2 100.0 159 Women's consultation clinic 98.0 1,206 77.2 11.4 8.6 1.4 1.4 100.0 1,171 Regional maternity/hospital 96.8 471 69.2 11.2 13.8 5.0 0.7 100.0 452 City maternity/hospital 97.8 715 81.9 11.7 4.4 1.8 0.2 100.0 696 * Excludes 17 births with unknown number of prenatal care visits. † Excludes 11 births with other source of prenatal care. FINAL REPORT 111 Table 6.3.1 Place of Delivery for Births in 2005–2010 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 City Maternity H it l Regional Maternity H it l Other At home Characteristic Place of delivery Total No. of Cases Hospital Hospital Other At home Total 54.7 43.6 0.5 1.2 100.0 2,617 Residence Urban 56.8 42.6 0.6 0.0 100.0 1,193 Rural 52.6 44.6 0.5 2.4 100.0 1,424 Regiong Kakheti 47.1 44.7 0.8 7.5 100.0 224 Tbilisi 55.9 44.0 0.2 0.0 100.0 567 Shida Kartli 74.0 25.9 0.0 0.0 100.0 168 Kvemo Kartli 37.6 60.9 0.8 0.8 100.0 234 Samtskhe–Javakheti 30.1 69.9 0.0 0.0 100.0 214 Adjara 45.3 52.2 0.0 2.4 100.0 176 Guria 53.5 46.5 0.0 0.0 100.0 140Guria 53.5 46.5 0.0 0.0 100.0 140 Samegrelo 78.5 18.7 1.4 1.4 100.0 184 Imereti 62.4 36.3 1.3 0.0 100.0 349 Mtskheta–Mtianeti 51.9 47.6 0.0 0.4 100.0 200 Racha–Svaneti 68.9 28.1 2.0 1.0 100.0 161 Age Group (at Birth) < 20 50.7 45.8 0.3 3.2 100.0 313 20 24 57 1 41 4 0 7 0 8 100 0 95620–24 57.1 41.4 0.7 0.8 100.0 956 25–34 55.2 43.6 0.3 0.9 100.0 1,164 35–44 46.4 50.6 1.7 1.1 100.0 184 Education Level Secondary incomplete or less 41.8 51.4 1.2 5.6 100.0 422 Secondary complete 54.4 44.3 0.5 0.8 100.0 738 Technicum/University 58.6 41.0 0.4 0.1 100.0 1,457 W lth Q i tilWealth Quintile Lowest 49.9 45.8 0.3 4.1 100.0 428 Second 54.7 41.7 1.2 2.4 100.0 628 Middle 53.1 46.1 0.5 0.3 100.0 587 Fourth 57.4 42.4 0.3 0.0 100.0 413 Highest 56.9 42.7 0.3 0.0 100.0 561 Ethnicity Georgian 59.1 39.8 0.5 0.5 100.0 2,248 Azeri 24.0 70.1 1.3 4.6 100.0 145 Armenian 20.1 78.3 0.0 1.6 100.0 145 Other 51.8 39.2 0.0 9.1 100.0 79 Birth Order First birth 57.6 41.5 0.5 0.4 100.0 1,293 Second birth 54.1 44.0 0.6 1.4 100.0 937Second birth 54.1 44.0 0.6 1.4 100.0 937 Third or higher 46.1 50.0 0.6 3.3 100.0 387 Baby s Weight at Birth* < 2500 grams 55.1 43.0 0.0 1.9 100.0 125 >= 2500 grams 54.8 43.7 0.6 0.9 100.0 2,481 * Excludes 11 births with unknown weight at birth. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 112 Table 6.3.2 Average Time between Admission and Delivery, and Nights Spent in a Medical Facility by Selected Characteristics Births in 2005–2010 Reproductive Health Survey: Georgia, 2010 No of Average Time (in Hours) Nights Spent in a Medical Facility Between Delivery and Discharge % No. of Cases* ≤ 4 5 6–7 8+ Total 3.8 2,077 56.3 25.1 14.7 4.0 100.0 2,589 Residence Urban 3.9 946 55.9 26.9 13.8 3.4 100.0 1,193 Rural 3.8 1,131 56.6 23.3 15.5 4.5 100.0 1,396 No. of CasesCharacteristic g ( ) and Discharge Total , , Region Kakheti 4.0 159 65.3 17.4 14.0 3.4 100.0 209 Tbilisi 4.0 469 60.3 26.0 10.7 2.9 100.0 567 Shida Kartli 3.3 141 57.8 28.1 12.4 1.6 100.0 168 Kvemo Kartli 4.0 189 64.8 21.9 10.9 2.3 100.0 232 Samtskhe–Javakheti 3.4 194 67.9 23.2 7.3 1.6 100.0 214 Adjara 3.1 136 40.5 24.5 26.5 8.5 100.0 171 Guria 4 1 109 47 2 23 9 24 5 4 4 100 0 140Guria 4.1 109 47.2 23.9 24.5 4.4 100.0 140 Samegrelo 3.8 133 51.9 28.6 15.5 3.9 100.0 181 Imereti 4.5 250 48.1 28.6 17.4 5.9 100.0 349 Mtskheta–Mtianeti 3.0 169 57.9 20.2 17.5 4.4 100.0 199 Racha–Svaneti 3.6 128 43.3 34.0 17.5 5.2 100.0 159 Age Group (at Birth) < 20 4.5 254 59.9 27.0 11.4 1.6 100.0 307 20–24 3.9 797 57.9 26.2 13.6 2.3 100.0 948 25–34 3.8 902 54.1 25.4 15.1 5.4 100.0 1,152 35–44 2.7 124 55.0 14.5 22.5 8.0 100.0 182 Education Level Secondary incomplete or less 3.6 326 63.3 23.5 10.4 2.8 100.0 401 Secondary complete 3.9 599 56.5 25.0 14.2 4.3 100.0 733 Technicum/University 3.9 1,152 54.2 25.6 16.0 4.2 100.0 1,455 Wealth QuintileWealth Quintile Lowest 3.8 340 55.1 22.4 18.5 4.0 100.0 416 Second 3.7 489 56.2 23.5 16.0 4.3 100.0 614 Middle 3.7 472 58.8 24.6 13.0 3.6 100.0 585 Fourth 4.2 329 54.6 25.4 15.3 4.7 100.0 413 Highest 3.9 447 55.9 28.2 12.5 3.4 100.0 561 Birth Order First birth 4.5 1,028 54.1 26.3 16.1 3.5 100.0 1,289 Second birth 3.2 745 59.0 24.4 12.5 4.1 100.0 927 Third or higher 3.1 304 57.3 22.6 14.8 5.4 100.0 373 Baby's Weight at Birth < 2500 grams 3.5 79 38.4 16.1 23.5 21.9 100.0 123 >= 2500 grams 3.9 1,994 57.1 25.6 14.2 3.1 100.0 2,461 Unknown † 4 † † † † 100.0 5 Type of DeliveryType of Delivery Vaginal 3.8 1,911 65.8 24.7 7.9 1.6 100.0 2,001 Cesarean Section 4.8 166 25.9 26.3 36.3 11.5 100.0 588 Pregnancy Complications Any Complication 4.2 278 39.5 31.7 20.6 8.2 100.0 379 No Complication 3.8 1,796 59.3 23.9 13.6 3.2 100.0 2,207 Does not remember † 3 † † † † 100.0 3† † † † † * Excludes 406 women who had C–section before labor and 106 with unknown duration of labor. † Fewer than 25 cases in this category. FINAL REPORT 113 Table 6.3.3 Percentage of Births Delivered by Cesarean Section by Selected Characteristics Among Births in 2005–2010 Delivered in Medical Facilities Reproductive Health Survey: Georgia, 2010 Characteristic Cesarean Deliveries % No. of Cases Total 23.9 2,589 Residence Urban 26.0 1,193 Rural 21.7 1,396 Region Kakheti 19.5 209 Tbilisi 22.8 567 Shida Kartli 19.5 168 Kvemo Kartli 16.4 232 Samtskhe–Javakheti 8.9 214 Adjara 28.5 171 Guria 23 3 140Guria 23.3 140 Samegrelo 33.0 181 Imereti 32.5 349 Mtskheta–Mtianeti 21.5 199 Racha–Svaneti 25.3 159 Age Group (at Birth) < 20 15.5 307 20–24 19.3 948 25–34 27.2 1,152 35–44 40.4 182 Education Level Secondary incomplete or less 16.4 401 Secondary complete 20.5 733 Technicum/University 27.5 1,455 Wealth Quintile Lowest 20.0 416Lowest 20.0 416 Second 22.5 614 Middle 22.6 585 Fourth 26.9 413 Highest 26.1 561 Birth Order First birth 25.7 1,289 Second birth 23.9 927 Third or higher 17.2 373 Pregnancy Complications Any Complication 35.7 379 No Complication 21.7 2,207 Does not remember * 3 Baby's Weight at Birth < 2500 grams 37.5 123 >= 2500 grams 23.2 2,461>= 2500 grams 23.2 2,461 Unknown * 5 Prolonged Labor† No 8.0 2,045 Yes 41.1 32 Does not remember 19.4 106 * Fewer than 25 cases in this category. † Excludes 406 C-sections performed before the onset of labor. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 114 Table 6.3.4 Cost of a Procedure for Delivery Among Deliveries Ended in 2005–2010 By Selected Characteristics Reproductive Health Survey: Georgia, 2010 Mean Payment None < 200 200–299 300–399 400–499 500–599 600 + Does not Remember Total 452.7 11.8 10.0 10.8 11.4 15.0 11.8 28.0 1.2 100.0 2,583 Residence Tbilisi 589.9 8.9 5.4 6.7 6.4 11.5 16.2 43.6 1.2 100.0 567 Other Urban 454.8 9.5 8.9 11.0 13.8 16.4 10.8 28.2 1.4 100.0 621 Rural 377.6 14.6 13.1 12.9 12.8 16.2 9.8 19.3 1.2 100.0 1,395 Mother's Age (at Birth) 15–24 442.0 10.7 10.8 11.9 12.1 15.5 12.5 25.8 0.7 100.0 1,253 25–34 456.6 12.3 9.6 10.3 10.6 14.8 11.4 29.1 1.9 100.0 1,149 35–44 501.4 16.3 8.0 6.9 10.9 12.8 8.6 35.5 1.0 100.0 181 Order of Live Births First birth 481.6 10.3 8.8 10.3 10.7 16.1 12.1 30.7 1.0 100.0 1,286 Second birth 439.2 12.0 11.1 10.5 11.7 15.6 11.5 26.3 1.2 100.0 924 Third birth 375.4 15.2 13.4 11.5 12.7 11.9 11.9 21.0 2.4 100.0 282 Fourth or higher 399.0 21.6 7.8 18.0 14.1 4.0 8.3 24.7 1.4 100.0 91 Education Level Secondary incomplete or less 341.3 15.0 14.6 13.5 16.3 12.3 10.4 15.3 2.7 100.0 400 Secondary complete 405.8 9.9 12.8 12.3 13.9 17.8 12.1 20.7 0.6 100.0 732 Technicum/University 505.1 11.9 7.5 9.4 8.8 14.4 12.0 34.9 1.2 100.0 1,451 Wealth Quintile Lowest 312.7 17.9 14.4 14.2 13.7 15.0 10.5 12.5 1.7 100.0 416 Second 365.2 12.9 12.9 13.3 14.4 15.8 10.4 19.1 1.3 100.0 611 Middle 431.0 12.3 13.4 11.8 13.0 16.1 9.4 23.0 1.0 100.0 584 Fourth 498.8 9.9 7.0 10.6 9.5 16.1 12.7 33.0 1.3 100.0 412 Highest 585.8 8.7 4.6 6.3 7.5 12.7 14.9 44.2 1.2 100.0 560 Ethnicity Georgian 460.7 11.7 10.1 10.0 10.5 15.7 12.1 28.8 1.0 100.0 2,230 Azeri 377.4 12.8 10.2 17.3 16.2 9.4 11.5 18.6 4.1 100.0 136 Armenian 356.6 10.8 11.1 19.8 20.5 10.9 7.0 18.6 1.2 100.0 143 Other 522.4 13.2 6.3 5.8 11.3 13.6 10.6 38.0 1.3 100.0 74 Place of Delivery Regional hospital, maternity 413.5 13.7 10.2 11.1 12.9 14.4 13.4 22.8 1.5 100.0 1,156 City hospital 484.5 9.7 10.0 10.7 10.0 16.1 10.5 32.1 1.0 100.0 1,345 Referral hospital 454.5 19.0 10.2 8.6 10.7 7.3 10.5 31.1 2.6 100.0 73 Other medical facility † † † † † † † † † 100.0 9 Type of Delivery Vaginal Delivery 385.2 12.5 12.7 12.8 13.0 15.6 12.3 19.5 1.5 100.0 2,000 Cesarean section 667.2 9.6 1.5 4.4 6.1 13.0 9.9 55.1 0.3 100.0 583 * Excludes 6 women who did not remember if they had paid for delivery. † Fewer than 25 cases in this category. Characteristic Cost of Delivery Total No. of Cases* FINAL REPORT 115 Table 6.4.1 Receipt of Postpartum Care and Information Given During Postpartum Visits Among Births in 2005–2010, by Selected Characteristics Reproductive Health Survey: Georgia, 2010 % No. of Cases Breast Feeding % Breast Care % Child Care % Immuniza- tion % Nutrition % Family Planning % No. of Cases Total 23.0 2,617 78.6 74.9 77.9 75.6 73.2 43.0 611 Postpartum Care Information Received During Postpartum Care Characteristic Total 23.0 2,617 78.6 74.9 77.9 75.6 73.2 43.0 611 Residence Tbilisi 27.6 567 85.0 81.7 84.4 85.6 82.8 46.1 160 Other Urban 28.6 626 77.4 74.6 75.5 72.7 72.5 47.7 172 Rural 17.9 1,424 74.4 69.6 74.4 69.6 66.1 37.0 279 Age Group (at Birth)Age Group (at Birth) < 20 20.1 313 81.1 75.6 80.4 81.4 74.8 39.1 65 20–24 21.8 956 77.9 72.9 73.7 71.0 71.2 39.2 212 25–34 24.9 1,164 75.8 73.3 78.0 75.2 72.1 43.9 290 35–44 23.1 184 96.2 93.2 93.3 90.9 87.8 61.7 44 Education Level Secondary incomplete 16 6 422 77 7 68 9 74 3 74 5 72 9 32 2 76Secondary incomplete or less 16.6 422 77.7 68.9 74.3 74.5 72.9 32.2 76 Secondary complete 18.0 738 78.1 72.3 79.2 71.2 67.5 33.7 134 Technicum/University 27.3 1,457 78.9 76.7 78.1 77.1 75.1 47.9 401 Wealth Quintile Lowest 12.3 428 73.7 67.0 73.7 67.9 65.3 36.2 69 Second 16.3 628 81.7 77.5 81.4 77.2 72.8 35.9 110 Middle 23.3 587 76.7 70.8 74.0 67.5 65.3 41.8 143 Fourth 30.7 413 74.6 70.2 73.5 72.3 71.9 41.4 118 Highest 29.4 561 82.3 81.3 82.7 84.0 81.4 49.9 171 Birth Order First birth 25.4 1,293 74.2 69.8 72.5 73.1 70.3 38.6 335 Second birth 22.1 937 83.8 80.3 83.3 76.3 75.9 46.0 206 Third or higher 17.3 387 85.1 84.3 88.6 85.8 79.9 56.8 70 Pregnancy Complications* Any Complication 27.6 380 71.6 71.9 68.9 68.6 62.3 36.3 112 No Complication 22.2 2,234 80.2 75.5 79.9 77.1 75.7 44.5 498 Postpartum CComplications Any Complication 43.6 296 64.1 64.6 65.5 62.3 56.4 26.3 132 No Complication 20.5 2,321 82.5 77.6 81.2 79.1 77.7 47.5 479 * Excludes 3 births with missing information on pregnancy complications. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 116 Table 6.4.2 Time Between Delivery and First Postpartum Visit by Selected Characteristics Among Mothers Who Had Any Postpartum Care Characteristics Among Mothers Who Had Any Postpartum Care after Delivering a Live Birth in 2005–2010 Reproductive Health Survey: Georgia, 2010 < 1 1 2 > 2 Does Not Characteristic Time Between Delivery and First Postpartum Visit (in Weeks) Total No. of Cases < 1 1–2 > 2 Does Not Remember Total 30.8 42.0 26.6 0.6 100.0 611 Residence Tbilisi 27.8 39.4 32.2 0.6 100.0 160 Other Urban 29.2 44.9 25.3 0.5 100.0 172 Rural 34 4 41 9 23 1 0 6 100 0 279Rural 34.4 41.9 23.1 0.6 100.0 279 Age Group (at Birth) < 20 31.8 37.7 30.6 0.0 100.0 65 20–24 33.8 37.4 28.4 0.5 100.0 212 25–34 28.1 44.6 26.4 0.8 100.0 290 35–44 31.5 54.3 14.1 0.0 100.0 44 Education Level Secondary incomplete or less 53.5 33.2 13.3 0.0 100.0 76 Secondary complete 24.8 45.3 28.8 1.0 100.0 134 Technicum/University 28.7 42.5 28.3 0.5 100.0 401 Wealth Quintile Lowest 35.5 44.4 15.0 5.1 100.0 69 Second 39.7 38.1 22.1 0.0 100.0 110 Middle 32.9 40.7 26.4 0.0 100.0 143 Fourth 26.6 46.2 27.1 0.0 100.0 118 Highest 26.9 41.4 31.2 0.5 100.0 171 Place of Delivery Regional maternity, hospital 35.1 45.8 18.7 0.5 100.0 287 City maternity, hospital 26.1 39.4 34.2 0.3 100.0 314y y, p Other * * * * 100.0 3 At home * * * * 100.0 7 Birth Order First birth 29.1 41.5 29.0 0.4 100.0 335 Second birth 29.1 45.8 24.1 1.0 100.0 206 Third or higher 44.3 33.2 22.5 0.0 100.0 70 * Fewer than 25 cases in this category. FINAL REPORT 117 Table 6.4.3 Use of Well–Baby Care and Time Between Delivery and First Visit by Selected Characteristics Among Live Births Delivered in Hospitals in 2005–2010 Reproductive Health Survey: Georgia, 2010 Time Between Delivery and First Postnatal % No. of Cases* < 1 1–2 > 2 Does Not Remember Total 84.1 2,624 21.7 53.4 23.7 1.2 100.0 2,369 Residence No. of CasesCharacteristic Time Between Delivery and First Postnatal Well-Baby Clinic Visit (in Weeks) Total Well-Baby Visit Urban 89.5 1,199 26.0 56.2 17.3 0.5 100.0 1,131 Rural 78.7 1,425 16.8 50.2 30.9 2.1 100.0 1,238 Region Kakheti 79.6 223 19.8 53.7 24.2 2.2 100.0 200 Tbilisi 91.9 572 28.6 56.7 14.0 0.8 100.0 553 Shida Kartli 87.0 168 7.0 46.5 44.2 2.3 100.0 157 Kvemo Kartli 74.7 233 19.3 55.0 24.3 1.4 100.0 196 Samtskhe–Javakheti 72.6 215 7.6 41.1 49.7 1.5 100.0 173 Adjara 81.7 179 28.8 59.9 11.3 0.0 100.0 150 Guria 86.2 141 11.4 60.4 27.5 0.7 100.0 132 Samegrelo 82.5 186 20.9 42.9 32.5 3.7 100.0 167 Imereti 85.7 349 19.5 56.3 23.4 0.8 100.0 325 Mtskheta–Mtianeti 83.5 197 26.5 41.7 31.8 0.0 100.0 185 Racha–Svaneti 72.4 161 15.5 36.6 47.8 0.0 100.0 131 Age Group (at Birth) < 24 84.3 1,266 20.0 53.5 24.7 1.8 100.0 1,143 25–34 84.7 1,170 24.0 52.9 22.3 0.8 100.0 1,062 35–44 79.6 188 19.0 55.2 25.8 0.0 100.0 164 Education Level Secondary incomplete or less 78.8 420 21.8 46.6 29.1 2.6 100.0 354 Secondary complete 79.3 743 16.4 53.7 27.4 2.5 100.0 639 Technicum/University 88.0 1,461 24.0 55.0 20.7 0.3 100.0 1,376 Wealth Quintile Lowest 75.4 430 16.7 46.4 35.1 1.8 100.0 353 Second 79.9 627 17.2 51.5 28.2 3.1 100.0 549 Middle 82.1 588 17.4 51.9 30.1 0.6 100.0 532 Fourth 86.6 414 27.0 53.2 18.8 1.0 100.0 383Fourth 86.6 414 27.0 53.2 18.8 1.0 100.0 383 Highest 92.4 565 27.3 59.2 13.3 0.2 100.0 552 Place of Delivery Regional maternity, hospital 82.2 1,160 20.5 56.5 21.7 1.4 100.0 1,018 City maternity, hospital 87.4 1,346 22.8 51.1 25.0 1.0 100.0 1,255 Referral hospital 65.5 76 20.5 51.2 28.3 0.0 100.0 63 Other medical facility † 9 † † † † 100.0 9Other medical facility † 9 † † † † 100.0 9 At home 53.9 27 14.9 49.8 21.1 14.3 100.0 18 Other † 6 † † † † 100.0 6 Birth Order First 85.9 1,305 21.4 54.1 23.2 1.4 100.0 1,207 Second 84.3 943 21.6 54.8 22.5 1.0 100.0 846 Third or more 77.3 376 23.0 46.7 29.1 1.2 100.0 316 * Includes 29 twins. † Fewer than 25 cases in this category. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 118 Table 6.4.4 Percentage of Babies with Birth Certificates and Time Between Delivery and Issuance of the Certificate By Selected Characteristics Among Live Births in 2005–2010—Reproductive Health Survey: Georgia, 2010 % No. of Cases* < 1 1–2 3–4 > 4 Does Not Remember Total 97.3 2,624 81.2 14.0 2.4 1.1 1.4 100.0 2,558 Residence Urban 98.1 1,199 84.0 12.5 1.8 0.7 1.0 100.0 1,176 Rural 96.5 1,425 78.2 15.4 3.0 1.4 1.9 100.0 1,382 Region Kakheti 92.5 223 72.0 18.6 3.0 1.3 5.1 100.0 210 Tbilisi 98.2 572 83.9 13.2 1.9 0.6 0.5 100.0 562 Shida Kartli 98.4 168 76.4 19.2 4.4 0.0 0.0 100.0 165 Kvemo Kartli 95.7 233 82.9 10.6 4.1 1.6 0.8 100.0 223 Samtskhe–Javakheti 98.8 215 88.6 2.9 2.0 2.4 4.1 100.0 212 Adjara 98.1 179 78.4 19.6 1.5 0.0 0.5 100.0 175 Guria 94.4 141 82.1 11.3 0.7 4.6 1.3 100.0 137 Samegrelo 97.6 186 75.4 19.3 1.9 1.9 1.4 100.0 181 Imereti 98.5 349 85.0 10.4 2.1 0.8 1.8 100.0 344 Mtskheta–Mtianeti 97.3 197 78.4 16.5 2.8 1.4 0.9 100.0 193 Racha–Svaneti 96.9 161 82.1 10.5 3.7 3.7 0.0 100.0 156 Age Group (at Birth) < 24 97.4 1,266 80.0 14.6 2.5 1.5 1.4 100.0 1,240 25–34 97.3 1,170 84.0 12.2 2.2 0.6 1.1 100.0 1,137 35–44 96.3 188 72.3 20.2 3.2 0.6 3.7 100.0 181 Education Level No. of CasesCharacteristic Baby Registered Interval Between Delivery and Birth Certificate (in Weeks) Total Education Level Secondary incomplete or less 92.2 420 77.8 15.2 2.8 2.0 2.1 100.0 394 Secondary complete 97.5 743 81.9 12.5 2.3 1.1 2.2 100.0 724 Technicum/University 98.7 1,461 81.7 14.3 2.3 0.8 0.9 100.0 1,440 Wealth Quintile Lowest 93.8 430 77.9 16.0 3.4 1.8 1.0 100.0 412 Second 97.4 627 76.5 17.9 2.0 1.0 2.6 100.0 612 Middle 98.1 588 80.1 12.7 2.8 2.1 2.4 100.0 574 Fourth 96.4 414 81.4 15.4 2.5 0.3 0.5 100.0 401 Highest 99.0 565 87.4 9.8 1.8 0.5 0.5 100.0 559 Place of Delivery Regional maternity, hospital 97.6 1,160 82.0 13.2 2.0 1.2 1.7 100.0 1,131 City maternity, hospital 97.7 1,346 82.5 13.6 2.5 0.9 0.6 100.0 1,317 Referral hospital 96.2 76 65.5 28.0 1.5 0.0 5.0 100.0 74 Other medical facility † 9 † † † † † 100.0 9 At home 67.3 27 14.2 20.7 25.3 10.0 29.8 100.0 21 Other † 6 † † † † † 100.0 6 Birth Order First 97.2 1,305 80.3 14.9 2.6 1.2 1.0 100.0 1,274 Second 97.8 943 82.5 13.3 2.4 0.6 1.2 100.0 923 Third or more 96.3 376 80.9 12.4 1.7 1.6 3.4 100.0 361 * Includes 29 twins. † Fewer than 25 cases in this category. FINAL REPORT 119 Table 6.6.1 Routine Measurement of Blood Pressure (BP) During Pregnancy, Reported High Blood Pressure (HBP) During Pregnancy, and Hospitalization Rate for HBP by Selected Characteristics Among Births in 2005–2010 Among Women with Any Prenatal Care Reproductive Health Survey: Georgia, 2010 Pregnancies Hospitalized for HBP (Exclusive) Pregnancies Hospitalized for HBP (Not Exclusive) % No. of Cases % No. of Cases % % Total 96.2 2,575 9.7 2,468 0.3 1.0 2,575 No. of CasesCharacteristic Routine Measurement of Blood Pressure Told Had High Blood Pressure Residence Urban 96.5 1,184 9.7 1,140 0.3 0.7 1,184 Rural 95.8 1,391 9.7 1,328 0.2 1.2 1,391 Region Kakheti 96.2 211 9.6 203 0.0 2.1 211 Tbilisi 97.5 563 10.1 548 0.3 0.8 563 Shida Kartli 94.1 168 9.8 160 0.0 1.1 168 Kvemo Kartli 97.6 223 8.3 217 0.4 1.2 223 Samtskhe–Javakheti 92.3 214 8.8 200 0.0 0.0 214 Adjara 92.2 175 12.8 159 0.0 0.5 175 Guria 93.7 140 6.7 130 0.0 0.0 140 Samegrelo 97.1 181 10.5 175 0.0 1.5 181 Imereti 97.4 348 8.7 338 0.8 1.0 348 Mtskheta–Mtianeti 96.4 194 9.8 186 0.0 0.9 194Mtskheta Mtianeti 96.4 194 9.8 186 0.0 0.9 194 Racha–Svaneti 95.9 158 8.1 152 0.0 0.0 158 Age Group (at Birth) < 24 95.7 1,251 8.2 1,194 0.3 0.5 1,251 25–34 96.3 1,145 9.5 1,099 0.2 1.5 1,145 35–44 98.0 179 21.4 175 0.6 1.0 179 Education Level Secondary incomplete 94.7 400 7.7 377 0.0 0.7 400Secondary incomplete or less 94.7 400 7.7 377 0.0 0.7 400 Secondary complete 96.5 724 9.9 694 0.6 1.0 724 Technicum/University 96.4 1,451 10.2 1,397 0.1 1.0 1,451 Wealth Quintile Lowest 95.6 410 8.2 389 0.3 1.5 410 Second 95.2 619 10.1 589 0.2 0.9 619 Middle 95 9 579 11 3 557 0 0 1 1 579Middle 95.9 579 11.3 557 0.0 1.1 579 Fourth 98.2 406 9.4 399 0.0 1.2 406 Highest 96.1 561 9.1 534 0.6 0.5 561 Place of Prenatal Primary care clinic/Fam.med.center 91.4 172 6.9 157 0.0 0.6 172 Women's consultation li i 95.5 1,206 9.9 1,151 0.2 0.3 1,206 clinic Regional 97.3 471 11.2 457 0.3 1.0 471 City maternity/hospital 97.7 715 9.1 692 0.5 1.9 715 Other * 11 * 11 * * 11 Birth Order First 95.7 1,285 10.2 1,227 0.4 1.1 1,285 Second 96.6 924 8.6 890 0.1 0.8 924 Third or more 96.7 366 11.0 351 0.0 0.8 366 * Fewer than 25 cases in this category. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 120 Ta bl e 6 .6. 2 Pr eg na nc y C om pl ica tio ns T ha t R eq ui re d Me di ca l A tte nt io n by S ele ct ed C ha ra ct er ist ics A m on g Bi rth s i n 20 05 –2 01 0 A m on g W om en w ith A ny P re na ta l C ar e Re pr od uc tiv e H ea lth S ur ve y: G eo rg ia, 20 10 At L ea st O ne Ri sk o f P re te rm An em ia Re lat ed W at er R et en tio n Hi gh B P Re lat ed Bl ee di ng D ur in g Ur in ar y T ra ct Bl ee di ng A fte r 6 Rh Pr eg na nc y C om pl ica tio n At L ea st O ne Pr eg na nc y Co m pl ica tio n % Ri sk o f P re te rm De liv er y % An em ia Re lat ed to P re gn an cy % W at er R et en tio n or E de m a % Hi gh B P Re lat ed to P re gn an cy % W ea k C er vix % Bl ee di ng D ur in g Fi rs t 6 M on th s % Ur in ar y T ra ct In fe ct io n % Bl ee di ng A fte r 6 Mo nt hs % Rh Iso im m un iza tio n % Ot he r % No . o f Ca se s To ta l 15 .7 7.9 3.6 3.3 3.0 2.1 1.9 1.5 1.1 1.0 1.6 2,5 75 Re sid en ce U b 15 0 71 37 31 27 26 21 14 14 09 16 11 84 Ch ar ac te ris tic Ur ba n 15 .0 7.1 3.7 3.1 2.7 2.6 2.1 1.4 1.4 0.9 1.6 1,1 84 Ru ra l 16 .3 8.6 3.6 3.6 3.4 1.6 1.6 1.7 0.8 1.1 1.5 1,3 91 Re gi on Ka kh eti 12 .7 6.8 5.9 2.5 2.5 1.7 1.3 0.4 1.3 2.1 0.8 21 1 Tb ilis i 13 .6 6.8 3.5 2.0 3.1 2.6 2.2 0.6 1.5 0.6 0.9 56 3 Sh ida K ar tli 22 .2 9.2 3.8 2.7 4.3 2.7 5.9 2.2 1.1 3.2 2.2 16 8 Kv em o K ar tli 14 .2 8.5 3.3 4.9 2.4 1.6 1.6 1.2 0.4 0.4 1.2 22 3 Kv em o K ar tli 14 .2 8.5 3.3 4.9 2.4 1.6 1.6 1.2 0.4 0.4 1.2 22 3 Sa mt sk he –J av ak he ti 14 .2 6.5 0.8 2.4 3.7 2.0 2.0 1.2 0.4 1.2 0.4 21 4 Ad jar a 17 .2 10 .3 0.5 4.4 3.9 1.0 1.5 2.9 1.5 0.5 2.0 17 5 Gu ria 4.4 0.6 1.3 1.3 0.6 0.6 1.3 0.6 0.0 0.0 0.0 14 0 Sa me gr elo 11 .7 7.8 2.4 2.9 2.4 2.4 0.5 1.0 1.0 1.0 1.0 18 1 Im er eti 20 .8 9.2 6.2 4.9 3.3 1.5 1.3 3.1 1.0 1.0 3.6 34 8 Mt sk he ta– Mt ian eti 23 .8 9.4 5.8 5.8 2.2 6.3 1.8 0.9 0.4 0.4 2.7 19 4 Ra ch a– Sv an eti 7.3 3.1 2.6 1.6 0.0 2.1 2.1 4.1 0.0 0.0 0.0 15 8 Ag e G ro up (a t B irt h) < 2 4 14 .2 7.4 3.1 2.3 2.2 2.2 1.4 1.3 0.8 0.8 1.2 1,2 51 25 –3 4 16 .6 7.9 4.2 4.2 3.2 1.9 2.7 2.0 1.4 1.0 2.3 1,1 45 35 –4 4 19 .8 11 .0 4.1 4.8 8.2 3.0 0.0 0.2 0.7 2.6 0.0 17 9 Ed uc at io n Le ve l Se co nd ar y i nc om ple te or le ss 13 2 71 16 42 20 24 00 12 06 07 19 40 0 Se co nd ar y i nc om ple te or le ss 13 .2 7.1 1.6 4.2 2.0 2.4 0.0 1.2 0.6 0.7 1.9 40 0 Se co nd ar y c om ple te 15 .9 7.3 4.1 2.9 2.8 2.1 2.1 2.2 1.2 1.2 1.5 72 4 Te ch nic um /un ive rsi ty 16 .2 8.4 4.0 3.3 3.4 2.0 2.3 1.3 1.1 1.0 1.6 1,4 51 W ea lth Q ui nt ile Lo we st 15 .0 6.4 3.2 3.6 3.1 1.4 1.0 2.3 0.8 2.4 1.8 41 0 Se co nd 15 .8 8.2 3.0 2.7 2.5 1.5 1.9 1.5 1.3 0.5 1.5 61 9 Mi dd le 15 .8 7.4 4.1 4.7 4.1 1.8 1.6 1.9 0.9 1.1 2.1 57 9 Fo ur th 17 .7 10 .6 4.7 4.7 2.3 4.4 2.8 1.5 2.8 0.5 1.7 40 6 Hi gh es t 14 .5 7.0 3.3 1.8 3.0 1.7 1.9 0.8 0.2 1.0 1.0 56 1 Bi rth O rd er Fir st 17 .1 9.1 3.7 3.2 3.3 2.5 2.3 1.8 1.4 0.7 1.6 1,2 85 Se co nd 13 .7 6.4 3.3 3.4 2.8 1.6 1.5 1.2 0.9 0.9 1.3 92 4 Th ird or m or e 15 .3 6.9 4.4 3.7 2.7 1.9 1.4 1.3 0.5 2.4 2.1 36 6 FINAL REPORT 121 Table 6.6.3 Postpartum Complications by Selected Characteristics among Births in 2005–2010 Reproductive Health Survey: Georgia, 2010 Postpartum Complication At Least One Postpartum Complication % Severe Bleeding % Painful Uterus % High Fever % Breast Infection % Bad–smelling Vaginal Discharge % Painful Urination % Infection of Surgical Wound % Faint/ coma % Other % Total 11.2 3.5 3.5 3.3 2.5 2.0 1.9 1.7 0.7 0.6 2,617 Residence Urban 12 6 4 6 3 8 3 8 3 2 2 2 2 2 1 9 0 8 0 8 1 193 No. of CasesCharacteristic Urban 12.6 4.6 3.8 3.8 3.2 2.2 2.2 1.9 0.8 0.8 1,193 Rural 9.7 2.4 3.1 2.7 1.8 1.8 1.7 1.5 0.6 0.3 1,424 Region Kakheti 13.3 3.5 4.3 3.5 2.7 2.0 2.7 1.6 0.0 0.0 224 Tbilisi 13.0 3.5 4.1 4.0 4.3 2.5 2.5 2.6 0.8 0.9 567 Shida Kartli 10.8 0.5 3.8 3.2 3.2 3.8 0.5 1.1 1.1 0.0 168 Kvemo Kartli 9.3 3.5 5.0 3.1 1.2 1.2 2.3 0.8 0.8 0.8 234 Samtskhe–Javakheti 6.1 3.7 1.6 0.4 0.4 0.4 0.4 1.2 0.4 0.4 214 Adjara 10 2 2 9 2 0 4 4 1 5 2 0 2 0 2 4 1 5 0 5 176Adjara 10.2 2.9 2.0 4.4 1.5 2.0 2.0 2.4 1.5 0.5 176 Guria 5.0 0.6 0.6 3.1 0.6 0.6 0.6 1.3 0.0 0.6 140 Samegrelo 5.7 0.5 1.9 1.9 1.0 1.0 0.5 1.9 0.5 0.0 184 Imereti 12.8 6.1 2.8 3.1 2.3 1.5 2.0 1.0 0.5 0.8 349 Mtskheta–Mtianeti 16.2 6.1 6.6 3.5 2.2 6.6 3.5 0.4 1.7 0.9 200 Racha–Svaneti 15.8 5.6 3.6 2.6 5.1 4.1 1.5 2.0 0.0 0.0 161 Age Group (at Birth) < 24 10 2 2 5 3 4 2 6 2 2 1 8 1 4 1 2 0 4 0 6 1 269< 24 10.2 2.5 3.4 2.6 2.2 1.8 1.4 1.2 0.4 0.6 1,269 25–34 12.8 4.4 4.0 4.3 3.1 2.3 2.5 2.2 1.0 0.6 1,164 35–44 8.1 4.9 1.2 1.6 0.8 1.6 1.7 1.8 0.6 0.2 184 Education Level Secondary incomplete or less 8.4 2.9 2.2 2.4 1.6 1.5 0.5 1.3 0.7 0.3 422 Secondary complete 10.2 2.6 2.7 2.7 1.4 1.9 1.5 1.1 0.5 0.4 738 Technicum/Universit 12.4 4.1 4.2 3.8 3.3 2.3 2.5 2.1 0.8 0.7 1,457 Wealth QuintileWealth Quintile Lowest 9.2 3.4 2.4 2.1 0.7 1.2 0.7 1.7 0.5 0.8 428 Second 8.0 2.7 2.8 1.8 1.3 1.2 1.2 1.3 0.7 0.0 628 Middle 11.7 3.6 3.9 3.8 2.3 2.7 2.6 1.7 1.1 0.4 587 Fourth 14.4 3.8 3.9 4.9 4.0 2.0 1.9 1.2 0.5 0.7 413 Highest 12.4 4.0 4.0 3.7 3.6 2.6 2.7 2.3 0.7 1.0 561 Birth Order First 11.4 2.9 3.5 3.9 2.9 2.0 2.1 2.1 0.8 0.7 1,293 Second 10 3 3 3 3 2 2 8 2 0 1 7 1 7 1 1 0 5 0 6 937Second 10.3 3.3 3.2 2.8 2.0 1.7 1.7 1.1 0.5 0.6 937 Third or more 12.2 6.0 3.9 2.3 2.1 2.8 2.1 1.7 1.1 0.3 387 Type of Delivery Vaginal 9.8 3.2 3.5 2.7 2.0 1.7 1.8 1.0 0.5 0.6 2,029 Cesarean Section 15.5 4.3 3.4 5.1 4.2 3.0 2.4 4.0 1.4 0.6 588 Baby s Weight at Birth < 2500 grams 37.3 24.9 8.9 7.8 2.0 8.5 3.0 2.8 2.2 1.5 125 2500 9 9 2 5 3 2 3 0 2 5 1 7 1 9 1 6 0 6 0 5 2 481>= 2500 grams 9.9 2.5 3.2 3.0 2.5 1.7 1.9 1.6 0.6 0.5 2,481 Unknown * * * * * * * * * * 11 * Excludes 11 births with unknown baby's weight at birth. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 122 Table 6.8.1 Percentage of Children Born in 2005–2010 Ever Breastfed and Time of Initiation of Breastfeeding by Selected Characteristics Reproductive Health Survey: Georgia, 2010 % No. of Cases* <1 Hour 1–23 Hours 24–47 Hours 48 Hours or More Unknown Total 87.4 2,624 19.7 54.5 13.3 11.3 1.2 100.0 2,278 Residence Urban 87.1 1,199 19.6 53.7 13.2 12.9 0.7 100.0 1,040 Rural 87.7 1,425 19.9 55.4 13.4 9.6 1.7 100.0 1,238 Region Kakheti 90.6 223 14.7 69.3 8.7 3.9 3.5 100.0 201 Tbilisi 88.3 572 22.1 54.5 11.9 11.0 0.5 100.0 503 Shida Kartli 85.9 168 13.8 41.5 24.5 20.1 0.0 100.0 144 Kvemo Kartli 88.3 233 21.6 57.3 8.8 9.7 2.6 100.0 204 Samtskhe–Javakheti 90.3 215 33.0 54.0 6.3 6.3 0.4 100.0 195 Adjara 83.7 179 8.6 56.3 23.6 11.5 0.0 100.0 146 Guria 82.5 141 18.9 45.5 18.9 16.7 0.0 100.0 117 Samegrelo 82.5 186 18.9 65.7 9.1 5.1 1.1 100.0 151 Imereti 88.8 349 19.8 47.4 14.1 17.2 1.4 100.0 311 Mtskheta–Mtianeti 86.2 197 32.6 42.0 13.5 10.4 1.6 100.0 168 R h S ti 85 7 161 24 4 38 7 22 6 13 1 1 2 100 0 138 No. of CasesTotal Children Ever BreastfedCharacteristic Initiation of Breastfeeding Racha–Svaneti 85.7 161 24.4 38.7 22.6 13.1 1.2 100.0 138 Age Group (at Birth) < 24 89.6 1,266 19.6 55.7 14.2 9.1 1.5 100.0 1,129 25–34 86.0 1,170 20.1 53.8 12.0 13.4 0.7 100.0 997 35–44 81.0 188 18.8 50.6 15.1 13.3 2.2 100.0 152 Education Level Secondary incomplete or less 88.1 420 16.2 64.6 11.6 5.1 2.6 100.0 366 Secondary complete 84.9 743 20.1 55.7 13.2 10.4 0.6 100.0 626 Technicum/University 88.4 1,461 20.6 51.1 13.9 13.4 1.1 100.0 1,286 Ethnicity Georgian 86.5 2,250 19.1 53.0 14.8 12.3 0.8 100.0 1,933 Azeri 92.0 145 18.5 65.9 7.7 4.1 3.8 100.0 133 Armenian 93.9 148 36.1 49.2 4.2 6.1 4.4 100.0 139 Other 91.1 81 13.4 73.3 4.3 7.9 1.1 100.0 73 Birth Order First 87.2 1,305 17.4 54.1 14.0 13.6 1.0 100.0 1,129 Second 88.6 943 22.3 53.3 13.4 9.8 1.1 100.0 827 Third or more 85.0 376 21.9 58.9 10.6 6.5 2.1 100.0 322 Type of Delivery Vaginal 88.6 2,022 23.8 57.8 9.9 7.2 1.2 100.0 1,787 Cesarean Section 83.6 602 6.1 43.5 24.6 24.8 1.0 100.0 491 Baby Weight at Birth < 2500 grams 64.2 113 11.0 40.4 18.8 28.3 1.5 100.0 68 >= 2500 grams 88.7 2,474 20.1 55.2 13.2 10.4 1.2 100.0 2,187 Unknown 64.2 37 † † † † † 100.0 23 * Includes 29 twins. † Fewer than 25 cases in this category. FINAL REPORT 123 Table 6.8.2 Characteristic Exclusive Breastfeeding * Full Breastfeeding Any Breastfeeding Total 3.0 4.1 12.2 Residence Tbilisi 2.9 3.8 10.3 Other Urban 2.8 3.4 12.1 Rural 3.1 4.5 13.2 Child's Sex Boy 2.5 3.7 12.8 Girl 3.4 4.4 11.2 Age Group (at Birth) <30 3.2 4.2 12.1 30-44 2.9 4.0 12.4 Education Level Secondary complete or less 3.3 4.5 12.8 Technicum/university 2.7 3.8 11.6 Ethnicity Georgian 2.9 4.0 11.9 Other 3.3 4.7 12.5 Quintile Lowest 4.1 5.2 13.9 Second 1.8 3.2 11.5 Middle 2.7 3.8 12.4 Fourth 3.1 4.3 11.8 Highest 2.7 3.2 10.2 Birth Order First 3.1 4.3 11.2 Second 2.9 4.1 13.0 Third or more 3.3 4.2 15.2 * Exclusive breastfeeding: child is fed only breast milk. Mean Duration of Breastfeeding in Months by Type of Breastfeeding and Reproductive Health Survey: Georgia, 2010 Selected Characteristics, for Live Births Aged 0–59 months † Full breastfeeding: includes both exclusive breastfeeding and almost exclusive breastfeeding (breast milk and other liquids excluding formula and other types of milk). ‡ Any breastfeeding includes: exclusive breastfeeding; almost exclusive breastfeeding; and complementary breastfeeding (breast milk and any food or liquid). Table 6.9.1 Among Children Born During the 5 Years Before the Survey Reproductive Health Surveys: Georgia 1999, 2005 and 2010 Rate CI Rate CI Rate CI Infant Mortality 14.1 (7.8–20.4) 21.1 (13.5–28.7) 41.6 (31.0–52.2) Neonatal 9.5 (5.4–13.4) 16.8 (10.7–22.9) 25.4 (17.0–33.8) Postneonatal 4.5 (0.0–9.1) 4.3 (1.2–7.4) 16.2 (9.1–23.3) Child Mortality (1–4) 2.3 (0.0–4.6) 4.0 (0.5–8.5) 3.8 (0.9–6.7) Under-5 Mortality (0–4) 16.4 (9.6–23.2) 25.0 (16.4–33.6) 45.3 (34.5–56.1) Number of Cases 2,170 1,909 2,507 Infant and Child Mortality Rates (Infant and Child Deaths per 1,000 Live Births) GERHS99: January 1995 – December 1999Mortality Rates GERHS10: January 2005 – December 2009 GERHS05: January 2000 – December 2004 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 124 Table 6.9.2 Infant and Child Mortality Rates (Infant and Child Deaths per 1,000 Live Births) Reproductive Health Survey: Georgia, 2010 Child Mortality Under–5 Mortality Total Neonatal Postneonatal 1–4 Year 0–4 Years Total 23.8 17.5 6.3 2.2 26.0 4,015 Period of Exposure January 2000/December 2004 35.7 27.2 8.5 2.2 37.9 1,845 January 2005/December 2009 14.1 9.5 4.5 2.3 16.4 2,170 Residence Urban 21.8 16.3 5.6 0.5 22.4 1,772 Rural 25.7 18.6 7.0 3.9 29.4 2,243 Region Kakheti 27.0 16.0 10.9 5.9 32.8 345 Tbilisi 16.9 14.7 2.1 0.0 16.9 839 Shida Kartli 28.2 21.2 7.0 7.5 35.5 257 Kvemo Kartli 28.1 16.5 11.6 2.4 30.4 384 Samtskhe–Javakheti 21.8 13.6 8.3 3.1 24.9 329 Adjara 26.6 19.8 6.8 3.7 30.3 261 Guria 21.3 14.2 7.1 0.0 21.3 251 Samegrelo 34.1 31.0 3.1 0.0 34.1 293 Imereti 19.7 12.4 7.2 1.9 21.6 515 Mtskheta–Mtianeti 38.0 34.8 3.2 0.0 38.0 281 Racha–Svaneti 6.8 3.4 3.3 0.0 6.8 260 Age Group (at Birth) < 25 18.2 12.9 5.3 1.5 19.7 2,118 25–44 30.1 22.6 7.5 3.2 33.2 1,897 Education Level Secondary incomplete or less 22.8 16.6 6.3 1.6 24.4 730 Secondary complete 28.4 22.1 6.3 2.8 31.2 1,132 Technicum/university 21.8 15.4 6.4 2.2 23.9 2,153 Ethnic Group Georgian 23.8 17.5 6.4 2.1 25.9 3,395 Other 23.5 17.3 6.2 2.9 26.3 620 Socioeconomic Status Low 26.0 19.9 6.1 1.6 27.5 1,685 Medium/High 22.4 16.0 6.4 2.6 25.0 2,330 Birth Order First 20.4 14.9 5.5 0.7 21.2 1,978 Second 23.1 16.1 7.0 3.5 26.5 1,464 Third or more 36.7 29.3 7.4 3.9 40.4 573 Length of Birth Interval First Birth 20.4 14.9 5.5 0.7 21.2 1,978 <24 months 22.4 20.0 2.4 3.0 25.4 637 24–47 months 34.8 29.5 5.3 6.2 40.7 689 48 moths or more 24.0 11.5 12.5 1.7 25.6 711 Sex of Child Boy 26.6 18.5 8.1 1.6 28.1 2,142 Girl 20.5 16.2 4.3 3.0 23.5 1,873 Infant Mortality No. of CasesCharacteristic by Selected Characteristics Among Children Born Between January 2000 and December 2009 125 CHAPTER 7 CONTRACEPTIVE KNOWLEDGE Contraceptive use is an important and direct deter- minant of variation in fertility and abortion rates. In Georgia, the availability of high quality contraceptive methods has been limited. Currently, Georgia does not have a stand-alone national family planning pro- gram, and neither state nor private health insurance packages include family planning provisions. However, family planning objectives are included in the nation- al reproductive health strategy, and specific targets are set to increase the use of modern contraceptive methods and reduce unmet need for family planning (MoLHSA, 2007). All family planning activities are maintained through donor support, primarily from the United Nations Population Fund (UNFPA) and the United States Agency for International Development (USAID). Since 1996–1999, both agencies have invest- ed heavily in numerous advances: building capacity; providing free contraceptive supplies in government clinics; integrating contraceptive services into primary care; training family planning providers; providing ser- vices to remote areas, minorities and internally dis- placed families; and funding information, education and communication efforts. Supplied contraceptive methods are available, either at no cost, at subsidized prices via social marketing programs, or at market prices in pharmacies and the commercial for-profit sector. Most health facilities with family planning services—hospitals, polyclinics, and primary health centers—provide oral contraceptives, condoms, and spermicides free of charge; free contraceptives are also distributed by mobile units. For a fee, tubal liga- tions and intrauterine device (IUD) insertions can be obtained in facilities that have trained obstetricians/ gynecologists on staff. The survey questionnaire addressed many family plan- ning topics such as knowledge of contraceptive meth- ods, use of methods in the past and present, sources of supply, contraceptive counseling, discontinuation and failure rates, reasons for non-use, desire to use in the future, exposure to family planning messages, and attitudes toward family planning. Selected topics are included in the present chapter. 7.1 Contraceptive Awareness and Knowledge of Use Limited knowledge about modern methods of contra- ception constitutes an important barrier to utilization of family planning services. To address this gap, the 2010 survey included questions on general aware- ness of specific contraceptive methods, knowledge of source(s) of supplied methods, perceived reliabil- ity (knowledge of contraceptive efficacy), and knowl- edge of how these methods are used. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 126 At first glance, women of reproductive age in Georgia appeared to be well informed about contraception. Virtually all (97%) had heard of at least one modern method, though fewer were aware of at least one tra- ditional method (64%) (Table 7.1.1). Levels of aware- ness of any method were lowest in the Kvemo Kartli region and highest in Tbilisi and Imereti. On average, women recognized 3.4 modern methods—ranging from 3.8 modern methods known by married wom- en and 2.7 modern methods known by women who have never been married. As expected, awareness increased directly with the age of the respondent; young adults knew, on average 2.6 modern methods while women aged 35 or older knew of almost 4 mod- ern methods (Table 7.1.2). Awareness of modern con- traception also increased with the level of education, from knowing on average 2.4 methods among women with less than complete secondary education to 4.0 methods among women with the highest education attainment (Table 7.1.3). Condoms (94%), IUDs (87%), and oral contraceptives (81%) were the best known methods regardless of marital status, age or educa- tion. Low awareness of tubal ligation, vasectomy, and in- jectable methods was common in all subgroups. Only 39% of women had heard of tubal ligation and fewer (4%) had heard of vasectomy. This low level of awareness is common among all former Soviet-bloc countries (Figure 7.1.1), which often limited access to tubal ligation as a means of contraception. In most countries of Eastern Europe, including Georgia, tubal ligation is either specifically permitted by law or is not specifically prohibited (and is, therefore, implicitly allowed). However, most countries have set certain conditions or limitations on surgical contraception (e.g. age or/and parity requirements, medical com- mittee approval, spousal consent) that are not always known by either providers or clients (EngenderHealth, 2002). For example, the USSR legalized tubal ligation in 1990 after a long period of prohibition (Ministry of Health of the USSR, Order No. 484 of December 14, 1990) and gave permission for tubal ligation only to women with 3 or more children or those over 30 years of age who already had 2 children (these restrictions were relaxed in 1993). After the dissolution of the So- viet Union in 1991 most successor states continued to regulate access to tubal ligation using the USSR legal statutes, although it was not clear that these restric- tions should still apply. Access to tubal ligation in Georgia is regulated by the Georgian Law on Health Care (Government of Geor- gia, 1997). Article 145 of the law stipulates that tubal ligation can be carried out only in certified medical fa- cilities by certified physicians after written consent of the patient and after a mandatory waiting period of one month from the time of initial discussion of the issue with the patient. Although the legal statute of tubal ligation is permissive, few women have enough knowledge about the method to make a decision whether they want to use it or not. Limited awareness about the use of tubal ligation as a method of family planning seems to be the most important deterrent to its use in Georgia. Among women interviewed in 2010 who wanted no more children, almost two-thirds had only limited knowledge about the procedure—lack of awareness about the procedure, not knowing where it can be obtained, fear of surgery or complications after surgery—are the most important reasons for not be- ing interested in tubal ligation (data not shown). Lack of awareness and misconceptions about oral contraceptives are another legacy of the former So- 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Percentage of Women Aged 15-44 Years Who Had Never Heard about Tubal Ligation Selected Countries in Eastern Europe and Central Asia* Figure 7.1.1 Uzbekistan 1996 Ukraine 2001 Turkmenistan 2000 Romania 1999 Moldova 1997 Kyrgyzstan 1997 Kazakhstan 1999 Georgia 1999 Georgia 2005 Georgia 2010 Azerbaijan 2001 Armenia 2001 Albania 2002 78 33 66 28 32 49 47 57 62 61 62 59 32 *Source: CDC and ORC/Macro, 2003. Reproductive, Maternal and Child Health in Eastern Europe and Eurasia: A Comparative Report FINAL REPORT 127 viet regime, particularly among older women. Un- der the Soviet regime, hormonal methods were not actively promoted for family planning purposes and were usually prescribed for medical benefits. Further, potential health risks and side effects sometimes asso- ciated with hormonal methods were overstated. As a result, some women of childbearing age in the former Soviet-bloc countries continue to be unaware of oral contraceptives (Figure 7.1.2). Awareness of contraception does not immediately translate into knowledge of how a contraceptive method should be used. Knowledge about how to use any modern method, or any traditional method, was much lower than the very high level of contracep- tive awareness in Georgia (76% vs. 96% and 51% vs. 64%, respectively). For the most widely known mod- ern contraceptive methods, there was a serious gap between awareness of the method and knowledge about how the procedure or product should be used (compare Tables 7.1.2 and 7.1.4 and Figure 7.1.3). Although condom and IUD awareness were almost universal, only two thirds of women stated they knew how to use condoms and only 59% said they knew how the IUD is used. Knowledge about using oral con- traceptives was much lower than awareness of it: 81% of women had heard of oral contraceptives, but only 50% had knowledge about how the method could be used. A considerable gap exists between awareness of other contraceptive methods and knowledge of how the procedures or products are used. On average, women reported having knowledge about how contraceptives work for about two mod- ern methods. The difference between awareness of, vs. knowledge about, use was greatest among never married women (93% vs. 58%) and young adults (94% vs. 63%); this difference diminished among married 1056 2734 841 1053 842 643 1005 1057 1684 845 1603 109,632 305,896 83,391 124,031 51,381 87,527 39,743 115,982 201,213 34,484 20,395 0 40,000 80,000 120,000 160,000 200,000 240,000 280,000 320,000 0 500 1000 1500 2000 2500 3000 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Households in CensusHouseholds in Sample Sample(RHS) Census(2002) Percentage of Women Aged 15–44 Years Who Had Never Heard about Oral Contraceptives Selected Countries in Eastern Europe and Central Asia* Figure 7.1.2 Albania 2002 Armenia 2001 Azerbaijan 2001 Georgia 2010 Georgia 2005 Georgia 1999 Kazakhstan 1999 Kyrgyzstan 1997 Moldova 1997 Romania 1999 Turkmenistan 2000 Ukraine 2001 Uzbekistan 1996 32 22 47 19 32 13 32 34 7 34 10 32 *Source: CDC and ORC/Macro, 2003. Reproductive, Maternal and Child Health in Eastern Europe and Eurasia: A Comparative Report 19 Awareness and Knowledge of How to Use Modern Contraceptive Methods among Women Aged 15–44 Years Figure 7.1.3 Percent Condoms 31 100 80 60 40 20 0 Oral Contraceptives Awareness Knowledge of Use Tubal Ligation Spermicides Vasectomy Emergency Contraception InjectablesIUD 95 68 88 59 81 50 39 29 21 16 4 3 4 5 4 5 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 128 women (99% vs. 92%) and among women aged 25–44 (98%–99% vs. 88%–92%). Never married and young adult women, on average, could identify how contra- ceptives work for 1.4-1.5 modern methods; women with marital experience and older women could iden- tify up to 3 modern methods. The low level of knowledge among never-married young women, often still in school, highlights the need to include information on contraceptive meth- ods in nationwide, age-appropriate sexual health edu- cation programs. The majority (84%) of women of reproductive age could name a source for at least one method of con- traception (Table 7.1.5). On average, women were able to name sources for about two contraceptive methods. Respondents were more likely to know a source for the most commonly used modern meth- ods. For instance, 77% of women knew a source for condoms, 67% knew where to obtain IUDs, and 65% knew a source for pills. Figure 7.1.4However, only 31% knew where tubal ligations were performed, and very few knew where vasectomies were performed or where to obtain injectables, spermicides, or emergen- cy contraception. Knowledge of a source was the higher among women living in Tbilisi (90%) and among those living in other urban areas (87%) than among rural residents (79%) (Table 7.1.5). As with other aspects of contraceptive knowledge, knowing a source for contraceptives in- creased with age. Regarding overall trends for modern contraception, all three aspects of awareness, knowledge about correct use, and knowledge of sources improved by 2010 (Ta- ble 7.1.6 and Figure 7.1.5). These improvements may be a result of recent efforts to increase access to fam- ily planning information in remote areas of Georgia, either through primary health care or through mobile health units. Knowledge about a Source for Specific Modern Contraceptive Methods Women Aged 15–44 Years Figure 7.1.4 Percentage Condoms 100 80 60 40 20 0 Oral Contraceptives Spermicides Emergency Contraception 77 67 65 31 17 3 4 4 Trends in Awareness of Modern Contraception, Knowledge of How Modern Methods Are Used and Where to get Modern Contraception Among Women Aged 15-44 years; 1999, 2005 and 2010 Figure 7.1.5 Awareness of modern contraception 120 100 80 60 40 20 0 95 Knowledge of how modern methods are used Knowledge of where to get modern contraception 97 96 74 75 77 78 80 84 1999 2005 2010 FINAL REPORT 129 However there were differences in trends for the in- dividual methods. Awareness of the IUD and tubal li- gation declined after 1999, but rose for the pill and condom (Table 7.1.6 and Figure 7.1.6); Interestingly, the gap between rural and urban awareness narrowed over the eleven years, but remained substantial, de- pending on the particular method. There were method differences also for knowledge about method use. Knowledge held steady (at a low level) for tubal ligation but fell for the IUD. After 1999 it rose for the pill and condom (Table 7.1.6 and Fig- ure 7.1.7). Again, the rural-urban gap narrowed over time. Finally, for knowledge of a source for obtaining a method, the results parallel those for knowledge about the methods themselves. Tubal ligation was flat at a low level; the IUD fell; and the pill and condom rose (Table 7.1.6 and Figure 7.1.8). The rural-urban difference persisted but diminished after 1999. These improvements may result from efforts to in- crease access to family planning information and modern contraceptives, mostly pills and condoms, throughout Georgia, either through primary health care or through mobile health units. 7.2 Most Important Source of Information about Contraception The 2010 survey found that for many women the main source of information about contraceptive methods was an acquaintance or a boy friend (32%), followed by a doctor (17%), a relative other than a parent (15%), a partner/husband (12%), and the TV, radio and inter- net (9%) (Table 7.2.1 and Figure 7.2.1). Parents and schools were seldom mentioned as important sources of contraceptive information (2% and 1%, respec- tively). Young women (those aged 15-24 ) reported somewhat different sources of information than older women did: 38% of young women found out about a contraceptive method in discussions with a friend or boy friend, 16% in discussions with relatives and 15% from audiovisual media. They were, however, less like- ly than women aged 25-34 or 35-44 to have learned about contraception from a health care provider (9% vs. 19% and 21%, respectively) and twice as likely to report television or radio or internet as their most important source of information about contraception (15% vs. 7% and 7%, respectively). Similar differences were found when never-married women were com- pared with ever-married women since the two groups differ so much in average age. The source of contraceptive information varied also by method (Table 7.2.2). Condoms were unusual in Trends in Awareness of Selected Modern Contraception Among All Women Aged 15-44 years; 1999, 2005 and 2010 Figure 7.1.6 1999 2005 2010 Tubal ligation IUD Oral Contraceptives 89 Condoms 95 95 68 81 81 93 94 88 44 39 39 Trends in Knowledge of How Modern Methods Are Used Among Women Aged 15-44; 1999, 2005 and 2010 Figure 7.1.7 1999 2005 2010 Tubal ligation IUD Oral Contraceptives Condoms 30 28 29 62 64 59 30 46 50 62 67 68 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 130 the dominance of the “grapevine” of friends, relatives, and the media, as opposed to doctors. However doc- tors ranked just below friends/boy friends for the pill, IUD, and tubal ligation as well as spermicides. Doc- tors and books came first however for vasectomy, in- jectables, and emergency contraception, all of which are not very well known at all. As for the withdrawal method, after partner/husband (39%), the second most important information source was a friend or boy friend (37%). An overview appears in Figure 7.2.2. These findings explain, in part, the poor quality of contraceptive information among the public, and il- lustrate the need to increase public health efforts in educating women about the benefits of contracep- tion, through the more reliable channels of schools, mass media, and health providers. 7.3 Knowledge about Contraceptive Effectiveness The 2010 survey addressed not only awareness of contraceptive methods and their sources, but also understanding of contraceptive effectiveness. Cor- rect information about contraceptive effectiveness can greatly influence couples’ decisions about how to prevent unplanned pregnancies. Good knowledge by the public about the effectiveness of specific con- traceptive methods is an indicator of the adequacy of contraceptive counseling and of information and education programs. In the latest survey a majority of women did not recognize any modern method as very effective (Table 7.3 and Figure 7.3.1). While 29% of women correctly stated that the IUD is very effec- tive in preventing pregnancy, only 16% believed that contraceptive sterilization is very effective. The major- ity of women incorrectly thought that pills were not very effective. In fact, the proportion of women who correctly said that pills were very effective was lower than the proportion who perceived the condoms as very effective (10% vs. 19%), although the document- ed use effectiveness of condoms is far lower than that of oral contraceptives (Hatcher et al., 2004). Misperceptions among users of traditional methods of contraception constitute a striking example of how lack of knowledge about contraceptive effectiveness can impair informed choice and increase reliance on less effective methods. Overall, 38% and 27% of wom- en, respectively, stated that the rhythm method and withdrawal are either very effective or effective. While the percentage of women who have heard of these methods declined from 2005 to 2010 (from 68% to 59% for rhythm and from 55% to 43% for withdrawal) (Table 7.1.6) belief in the high effectiveness of tradi- tional methods is in fact the predominant view among women who are aware of these methods. That is, in Trends in Knowledge of Where to Get Modern Contraception Among Women Aged 15-44; 1999, 2005 and 2010 Figure 7.1.8 1999 2005 2010 Tubal ligation IUD Oral Contraceptives Condoms 34 30 31 68 71 67 46 61 65 66 74 77 Main Source of Information about Contraception by Age Group Among Women Aged 15-44 Who Have Heard of Specific Methods Figure 7.2.1 Total 15-24 25-34 35-44 32 17 15 12 9 38 9 16 6 15 31 19 15 15 7 29 21 14 15 7 Friends Doctor Relative Partner TV/Radio FINAL REPORT 131 Table 7.3, 42% and 56% have never heard of the two methods and so when they are removed, most of the rest fall into the very effective and effective columns. Further information regarding trends appears in Figure 7.3.1. The trends are rather erratic, and the reasons are not entirely clear. Between 1999 and 2005, the perceived effectiveness of the IUD and oral contracep- tive increased (from 31% to 40% and from 9% to 13%, respectively). However, then the levels declined in 2010 close to the 1999 levels, reaching 29% and 10%, respectively. Belief that tubal ligation is very effective declined by half between 1999 and 2005 (from 28% to 14%) and remained approximately constant from 2005 to 2010. In summary, there are large deficits in public aware- ness of particular methods, as well as knowledge about how to use them and where to obtain them. Perceptions of method reliability are confused, and in- volve serious misunderstandings that tend to increase unplanned pregnancies and abortions. Clearly, pro- grams are needed to address these widespread prob- lems, to strengthen current efforts to educate both the public and the providers of modern contraception. Percentage of Women Agreeing that Specified Contraceptive Methods* Are Very Effective in Preventing Pregnancy Among Women Aged 15-44 Figure 7.3 1999 2005 2010 Tubal ligation IUD Oral contraceptives Condoms 28 40 35 30 25 20 15 10 5 0 14 16 31 40 29 9 13 10 28 21 19 * Presented from left to right in the descending order of contraceptive effectiveness when the method is used correctly and consistently REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 132 Table 7.1.1 Percentage of All Women Aged 15–44 Who Had Heard of Specific Methods of Contraception by Region Reproductive Health Survey: Georgia, 2010 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti Ever Heard of Any Method 96.6 95.7 98.9 97.0 90.6 95.0 95.4 99.2 98.3 96.8 97.5 96.3 Ever Heard of a Modern Method 96.2 95.3 98.9 97.0 88.7 94.4 95.0 98.6 98.3 96.5 97.5 96.1 Condoms 94.5 93.8 98.4 95.7 83.1 92.7 90.8 98.2 97.6 95.9 94.9 95.4 IUD 87.5 85.1 90.9 85.0 81.3 88.2 84.7 90.4 84.7 91.1 88.4 84.2 Pill 81.1 79.1 89.5 80.9 74.9 73.9 72.8 79.2 73.8 83.6 84.6 76.7 Tubal ligation 39.3 36.4 44.3 47.1 30.1 24.7 19.2 46.2 41.2 51.0 37.8 36.6 Spermicides 20.7 19.3 28.4 16.8 18.7 9.6 16.3 18.6 12.9 23.1 18.8 13.0 Emergency contraception 5.2 3.2 10.2 2.4 3.6 1.2 3.9 1.6 0.8 4.8 5.7 3.0 Injectables 4.8 2.8 9.3 3.4 3.4 1.7 3.2 4.6 2.5 3.2 4.9 3.6 Vasectomy 4.2 2.8 8.4 1.6 1.7 0.9 2.5 2.6 2.2 4.2 2.3 2.0 Average Number of Modern Methods 3.4 3.2 3.8 3.3 3.0 2.9 2.9 3.4 3.2 3.6 3.4 3.1 Awareness of Contraception Total Region Ever Heard of a Traditional Method 63.7 62.2 67.9 63.1 60.4 66.6 59.0 61.2 55.6 67.0 65.6 59.5 Calendar (rhythm) method 58.5 57.4 64.7 60.4 48.1 55.6 51.3 51.6 51.6 64.4 62.4 54.9 Withdrawal 43.2 37.0 42.8 40.6 46.6 50.9 49.4 45.8 32.1 44.6 46.4 40.0 No. of Cases 6,292 498 1,426 392 546 481 419 401 477 805 393 454 FINAL REPORT 133 Table 7.1.2 Percentage of All Women Aged 15–44 Who Had Heard of Specific Methods of Contraception by Marital Status and Age Group Reproductive Health Survey: Georgia, 2010 Married Previously Married Never Married 15–24 25–34 35–44 Ever Heard of Any Method 96.6 98.6 96.8 93.0 93.8 97.9 98.6 Ever Heard of a Modern Method 96.2 98.1 96.3 93.0 93.7 97.7 97.7 Condoms 94.5 96.1 95.0 91.5 91.6 96.7 95.5 IUD 87.5 95.9 94.7 71.8 73.7 95.2 96.0 Pill 81.1 89.7 89.7 64.7 65.8 90.4 89.6 Tubal ligation 39.3 48.6 50.8 21.0 19.1 46.5 55.9 Spermicides 20.7 27.2 29.9 7.8 8.1 26.1 30.2 Emergency contraception 5.2 6.2 9.5 2.6 1.8 6.6 7.7 Injectables 4.8 5.6 7.3 3.0 2.1 5.2 7.8 Awareness of Contraception Total Marital Status Age Group j s 8 5 6 3 3 0 5 8 Vasectomy 4.2 4.5 7.8 2.8 1.3 4.8 7.0 Average Number of Modern Methods 3.4 3.7 3.8 2.7 2.6 3.7 3.9 Ever Heard of a Traditional Method 63.7 83.0 74.9 28.5 34.0 77.4 85.1 Calendar (rhythm) method 58.5 75.3 71.6 27.0 30.3 70.6 79.5 Withdrawal 43.2 62.0 56.7 8.2 15.9 53.8 64.8 No. of Cases 6,292 4,098 389 1,805 1,960 2,359 1,973 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 134 Table 7.1.3 Percentage of All Women Aged 15–44 Who Had Heard of Specific Methods of Contraception by Education Reproductive Health Survey: Georgia, 2010 Secondary Incomplete or Less Secondary Complete Technicum University/ Postgraduate Ever Heard Any Method 96.6 91.2 96.1 99.1 99.1 Ever Heard of a Modern Method 96.2 90.0 95.8 99.0 99.1 Condoms 94.5 87.4 93.2 97.2 98.5 IUD 87.5 69.5 86.7 97.4 95.1 Pill 81.1 59.2 77.5 90.8 92.7 Tubal ligation 39.3 19.9 30.6 51.6 51.6 Spermicides 20.7 6.7 12.5 28.0 31.5 Emergency contraception 5.2 0.5 2.1 7.1 9.1 Injectables 4.8 0.9 1.7 4.3 9.2 Vasectomy 4.2 0.2 1.2 5.5 7.9 Awareness of Contraception Total Education Level Average Number of Modern Methods 3.4 2.4 3.1 3.8 4.0 Ever Heard of a Traditional Method 63.7 40.3 59.3 79.5 74.7 Calendar (rhythm) method 58.5 33.2 51.3 76.7 71.4 Withdrawal 43.2 27.9 41.1 51.1 50.6 No. of Cases 6,292 1,330 1,568 903 2,491 FINAL REPORT 135 Table 7.1.4 Percentage of All Women Aged 15–44 Who Said They Know How Selected Methods of Contraception Are Used, by Marital Status and Age Group Reproductive Health Survey: Georgia, 2010 Married PreviouslyMarried Never Married 15–24 25–34 35–44 Know How to Use at Least One Method 79.9 92.0 87.9 57.5 62.9 87.9 91.8 At Least One Modern Method 76.5 87.3 85.5 56.2 61.1 84.3 86.8 Condoms 67.5 76.4 77.9 50.3 54.7 75.0 74.8 IUD 58.5 72.1 69.3 33.1 37.2 67.5 74.7 Pill 49.7 61.1 61.9 27.8 32.2 58.9 61.1 Tubal ligation 29.0 37.2 39.7 12.9 11.9 34.6 43.8 Spermicides 16.0 21.2 25.3 5.2 5.8 20.0 24.0 Emergency contraception 4.0 4.8 7.9 2.1 1.3 5.0 6.4 Injectables 3.5 3.9 6.8 2.2 1.3 3.5 6.3 Vasectomy 3.4 3.6 7.3 2.2 1.1 3.9 5.6 Average Number of Modern Methods 2.3 2.8 3.0 1.4 1.5 2.7 3.0 Knowledge of Contraceptive Use Total Marital Status Age Group Modern Methods At Least One Traditional Method 50.5 69.3 62.0 15.9 22.5 61.9 72.0 Calendar (rhythm) method 41.9 56.2 55.2 14.8 18.2 50.4 61.4 Withdrawal 34.8 50.7 45.4 5.4 12.3 43.4 52.8 No. of Cases 6,292 4,098 389 1,805 1,960 2,359 1,973 Table 7.1.5 Percentage of All Women Aged 15–44 Who Said They Know Where to Get Selected Methods of Contraception, by Age Group and Residence Reproductive Health Survey: Georgia, 2010 Tbilisi Other Urban Rural 15–24 25–34 35–44 Know Where to Get at Least One Method 84.1 90.1 86.9 79.0 75.6 88.8 89.2 Condoms 77.4 85.1 80.2 71.4 70.5 82.0 80.9 IUD 66.5 68.9 69.8 63.2 48.0 75.2 79.4 Pill 64.7 73.3 67.6 58.2 50.2 73.6 72.8 Tubal ligation 30.6 33.9 32.7 27.5 13.0 36.8 45.2 S i id 17 1 21 8 20 6 12 5 6 4 21 1 25 7 Knowledge of a Source of Contraception Total Age Group Residence Spermicides 17.1 21.8 20.6 12.5 6.4 21.1 25.7 Emergency contraception 4.1 8.0 3.3 2.3 1.3 5.2 6.5 Injectables 3.7 6.3 3.2 2.5 1.5 3.7 6.4 Vasectomy 3.4 6.7 2.7 2.0 1.1 3.9 5.8 Average Number of Modern Methods 2.3 2.7 2.5 2.0 1.5 2.7 3.0 No. of Cases 6,292 1,426 1,549 3,317 1,960 2,359 1,973 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 136 Table 7.1.6 Trends in Awareness of Contraceptive Methods, Knowledge of How Contraceptive Methods Are Used, and Knowledge of Where to Get Modern Methods, by Residence, Among All Women Aged 15–44 Reproductive Health Surveys, Georgia 1999, 2005 and 2010 Urban Rural Urban Rural Urban Rural Any Method 95.1 98.2 91.3 96.9 99.5 93.8 96.6 98.4 94.6 Any Modern Method 94.9 98.0 90.8 96.7 99.4 93.4 96.2 98.3 93.9 Condoms 88.5 95.5 79.3 95.2 99.2 90.3 94.5 97.3 91.3 IUD 92.6 95.9 88.3 93.9 96.8 90.3 87.5 90.0 84.8 Pill 67.5 77.7 54.4 81.3 88.4 72.7 81.1 87.2 74.2 Tubal ligation 43.5 48.5 37.0 38.5 47.7 27.4 39.3 42.6 35.5 Spermicides 11.3 14.6 6.9 18.4 23.6 12.1 20.7 25.8 15.0 Vasectomy 12.4 16.9 6.6 5.1 7.6 2.1 4.2 5.9 2.2 Emergency contraception 4.1 6.0 1.6 4.2 6.2 1.8 5.2 7.4 2.7 Injectables 4.3 5.8 2.5 3.3 5.2 1.1 4.8 6.6 2.8 Any Traditional Method 69.4 74.0 63.5 72.5 77.1 67.0 63.7 66.2 61.0 Calendar (rhythm) method 64.9 71.0 57.0 68.2 74.2 60.8 58.5 62.7 53.6 Withdrawal 50.3 53.6 46.1 54.9 58.0 51.0 43.2 42.6 43.9 Any Method 77.9 83.3 70.9 79.4 83.2 74.7 79.9 83.4 75.9 Any Modern Method 73.5 80.4 64.7 75.1 79.9 69.4 76.5 81.5 70.9 Condoms 62.2 71.3 50.4 66.6 72.8 59.2 67.5 73.7 60.4 IUD 61.8 67.0 55.2 64.0 67.6 59.6 58.5 62.1 54.5 Pill 30.1 36.9 21.4 45.9 50.2 40.6 49.7 54.7 44.2 Tubal ligation 30.1 35.2 23.6 28.3 35.4 19.5 29.0 32.5 25.1 Spermicides 7.0 9.6 3.6 11.5 14.8 7.6 16.0 20.3 11.0 Vasectomy 8.9 12.0 4.9 3.5 5.3 1.3 3.4 4.7 1.9 Emergency contraception 2.7 4.1 1.0 2.5 3.9 0.8 4.0 5.7 2.2 Injectables 2.6 3.8 1.0 1.7 2.5 0.7 3.5 4.8 2.1 Any Traditional Method 52.1 56.4 46.5 55.5 58.9 51.3 50.5 51.4 49.4 Calendar (rhythm) method 43.0 49.0 35.3 46.7 52.3 39.9 41.9 45.6 37.7 Withdrawal 37.9 40.0 35.1 41.3 43.0 39.2 34.8 33.0 36.8 Any Modern Method 77.5 83.8 69.4 80.4 84.2 75.7 84.1 88.5 79.0 Condoms 65.8 75.7 53.1 74.2 79.6 67.6 77.4 82.8 71.4 IUD 67.9 73.5 60.7 70.6 74.0 66.4 66.5 69.3 63.2 Pill 45.8 55.3 33.5 61.4 67.6 54.0 64.7 70.6 58.2 Tubal ligation 34.0 38.7 27.9 30.1 37.2 21.5 30.6 33.3 27.5 Spermicides 8.4 11.3 4.6 13.6 17.6 8.8 17.1 21.2 12.5 Vasectomy 9.4 12.7 5.2 4.1 5.8 1.9 3.4 4.7 2.0 Emergency contraception 2.9 4.5 0.8 3.0 4.6 1.1 4.1 5.8 2.3 Injectables 2.6 3.7 1.1 2.0 3.0 0.7 3.7 4.8 2.5 No. of Cases 7,798 4,759 3,039 6,376 3,196 3,180 6,292 2,975 3,317 Knowledge of How Contraceptive Methods Are Used Knowledge of Where to Get Modern Methods of Contraception Residence ResidenceContraceptive Method Awareness of Contraception 2010 Residence Total Total Total 1999 2005 FINAL REPORT 137 Table 7.2.1 Most Important Source of Information About Contraception by Age Group and Marital Status Among Women Aged 15–44 Who Have Heard of at Least One Method of Contraception Reproductive Health Survey: Georgia, 2010 15–24 25–34 35–44 Married Previously Married Never Married Friends, boyfriend 32.1 37.6 30.6 29.0 28.7 30.9 41.6 Doctor 17.0 8.9 19.5 21.2 22.3 17.2 2.6 Relative 15.3 16.5 15.3 14.4 14.7 14.0 17.4 Partner/husband 12.2 6.2 14.6 14.8 16.3 16.0 0.0 TV/Radio/internet 9.1 14.5 7.0 6.7 6.0 7.3 17.9 Co–worker, colleagues, peers 4.2 3.3 4.4 4.8 3.8 6.1 4.9 Mother or father 2.5 4.8 1.9 1.0 1.7 1.9 4.6 Books 2.2 2.1 1.8 2.8 1.8 3.6 3.0 Newpapers, magazines, brochures, flyers 1.8 1.6 1.5 2.2 1.6 1.2 2.5 Teacher 0.8 1.6 0.6 0.5 0.4 0.5 2.1 Nurse, midwife, feldcher, CHW 0.2 0.1 0.2 0.3 0.3 0.0 0.1 Other 1.5 1.7 1.4 1.4 1.4 0.8 2.1 Does not remember 1.0 1.2 1.1 0.9 1.0 0.5 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 6,123 1,854 2,319 1,950 4,050 378 1,695 Source Marital Status Total Age Group Table 7.3 Opinions Regarding Contraceptive Effectiveness of Specific Methods Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Very Effective Effective Not Effective Does Not Know Never Heard Tubal ligation 16.3 17.9 0.4 4.6 60.7 100.0 6,292 IUD 29.5 43.1 1.7 13.2 12.5 100.0 6,292 Pill 10.1 53.3 2.3 15.5 18.9 100.0 6,292 Condoms 19.2 59.1 1.5 14.7 5.5 100.0 6,292 Contraceptive Method* Total No. of Cases Contraceptive Effectiveness Calendar (rhythm) method 4.7 33.5 10.0 10.2 41.5 100.0 6,292 Withdrawal 3.4 23.9 8.6 7.2 56.8 100.0 6,292 * Listed in the descending order of contraceptive effectiveness when the method is used correctly and consistently (Hatcher et al., 1998). REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 138 Ta bl e 7 .2. 2 Mo st Im po rta nt S ou rc e o f I nf or m at io n Ab ou t C on tra ce pt ive M et ho ds A m on g W om en A ge d 15 –4 4 W ho H av e H ea rd o f a t L ea st O ne M et ho d of C on tra ce pt io n Re pr od uc tiv e H ea lth S ur ve y: G eo rg ia, 20 10 Pi ll IU D Co nd om s Sp er m ici de s Tu ba l Li ga tio n Va se ct om y In jec ta bl es Em er ge nc y Co nt ra ce pt io n Ca len da r (R hy th m ) Me th od W ith dr aw al Fr ien ds , b oy frie nd 32 .1 39 .8 37 .8 41 .9 35 .2 33 .8 11 .6 15 .1 27 .9 46 .4 37 .4 Do cto r 17 .0 25 .3 32 .2 8.7 28 .8 25 .1 22 .6 25 .3 25 .2 13 .2 3.6 Re lat ive 15 .3 12 .2 15 .6 6.9 9.0 17 .4 3.2 5.0 4.5 25 .2 11 .3 Pa rtn er /hu sb an d 12 .2 0.1 0.2 17 .1 0.6 0.3 0.4 0.3 0.3 0.6 39 .3 TV /R ad io/ Int er ne t 9.1 8.7 2.5 14 .6 4.7 5.5 10 .0 11 .1 6.4 0.6 0.3 Co –w or ke r, co lle ag ue s, 4.2 3.5 3.8 4.1 6.3 4.0 6.8 8.9 9.0 4.5 4.0 Mo the r o r f ath er 2.5 1.4 2.6 0.8 0.2 1.2 0.4 0.6 0.0 3.2 0.2 Bo ok s 2.2 2.8 1.9 1.3 5.4 6.1 28 .0 15 .4 13 .0 2.5 1.5 Ne wp ap er s, ma ga zin es , 1.8 1.7 0.9 1.5 2.9 2.6 7.4 7.5 4.3 0.9 0.4 Te ac he r 0.8 1.2 1.0 0.8 2.2 2.4 8.4 6.5 4.5 1.0 0.4 Nu rse , m idw ife , fe ldc he r, 0.2 0.2 0.1 0.0 0.1 0.2 0.0 0.3 0.3 0.3 0.1 Ot he r 1.5 2.3 0.9 1.6 4.2 0.4 1.1 1.9 3.2 0.7 0.2 Do es no t r em em be r 1.0 0.7 0.6 0.8 0.3 1.0 0.4 2.0 1.3 0.9 1.5 To ta l 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 10 0.0 No . o f C as es 6,1 23 5,2 37 5,6 52 6,0 06 1,3 46 2,6 14 25 9 30 6 32 6 3,9 06 2,9 58 So ur ce To ta l Me th od o f C on tra ce pt io n 139 CHAPTER 8 CONTRACEPTIVE USE This chapter begins by examining ever use of contra- ception, among all women regardless of marital sta- tus. Most use is among currently married women, discussed later, and some use is among previously married women; very little use occurs among the never married. Therefore the percentages ever using among all women, just below, are considerably less than the percentages for currently married women. 8.1 Ever use of contraceptives In Georgia the percentages for ever use are not high, indicating that adoption of contraceptive use, particu- larly of methods of high efficacy, is quite recent. Also, the percentages for all women are depressed by the inclusion of unmarried women. However the trend since 1999 is of interest (Figure 8.1.1.; see also Table 8.1.1). The use of modern methods has increased reg- ularly while that for traditional methods has declined. The net result is an increase in the overall percent who have ever used a method. Note that an overlap exists between modern and tra- ditional methods since some women have used both. Therefore the two figures cannot be added. The bars to the right show that in 2010 46% of all women had ever used a method, up from 38% in 1999. These percentages are much higher for married women as shown in Table 8.1.2. The highest figures for ever use among all women are for ages 30 and higher (67%-70%), especially high for two or more children (82%-86%), upper education 51%-56%), and the highest wealth quintile (52%). Surprisingly there is very little difference according to ethnicity for any method, but Georgian women use modern methods more and traditional method less than the Azeri or Armenian women do. In Figure 8.1.2 ever use of any method ranged from a high of 49% in Shida Kartli to a low of 41% in Racha-Svaneti. Notably, ever use of modern methods is higher than for traditional methods in nearly every category shown in Table 8.1.2. That pattern holds true for eve- ry age group, as shown in Figure 8.1.3. In Table 8.1.3 the most commonly used methods ever used were condoms (20%), calendar (rhythm) method (17%), IUDs (16%) and withdrawal (15%). Regarding trends (Figure 8.1.4) between 1999 and 2010, the percentage of women who reported that their part- ner had ever used a condom almost doubled (from 10%, to 13%, to 20%). As a result, condoms became the most ever-used method in 2010, followed by the REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 140 calendar (rhythm) method, which was reported as the leading method in the 1999 and 2005 surveys. The percentage of women who had ever used an IUD increased slightly (from 14% to 16%). Ever-use of the rhythm method appears to have plateaued between 1999 and 2010 at 17–18%. The percentage of women whose partner had ever used withdrawal decreased from 17% in 2005 to 15% in 2010, but was still higher than the 1999 level of 12%. Ever use of oral contracep- tives increased slightly but not significantly from 6% in 1999 to 8% in 2005 and 10% in 2010. The percentage who had ever used spermicide products, injectables, emergency contraception and tubal ligation did not increase or registered a small increase between 2005 and 2010. Only one woman reported that her partner had a vasectomy. Changes in Contraceptive Status in Georgia Among All Women Aged 15-44; 1999, 2005 and 2010 Figure 8.1.1 1999 2005 2010 Used by modern method 25 Used by traditional method Never used 29 36 29 27 25 62 58 54 Ever-use of Any Contraception Among Women Aged 15-44 Years by Region Figure 8.1.2 KakhetiTbilisiShida Kartli Kvemo Kartli Samtskhe- Javakheti AdjaraGuria Samegrelo ImeretiMtskheta- Mtianeti Racha- Svaneti 49 48 47 47 46 45 46 46 46 41 41 KakhetiTbilisi Kvemo Kartli Samtskhe- Javakheti AdjaraGuria Samegrelo ImeretiMtskheta- Mtianeti Racha- Svaneti 49 48 47 47 46 45 46 46 46 41 41 Ever-use of Contraception by Type of Method by Age Group Among All Women Aged 15-44 Figure 8.1.3 15-19 20-24 25-29 35-39 40-44 1 3 4 11 25 44 42 23 40 53 51 30 51 70 69 Traditional Modern Any Method FINAL REPORT 141 8.2 Current Use of Contraceptives At the time of the survey, 32% of all women aged 15– 44 years (or about 317,000 women) were currently using a contraceptive method including 21% (about 207,000 women) who were using modern methods (condoms, IUDs, pills, tubal ligation, and spermicides) (Table 8.2.1 and Figure 8.2.1). In general, the most commonly used method was the condom, followed by the IUD, withdrawal and the rhythm method (also known as the calendar method). Oral contraceptives were used by 2.4% of women and tubal ligation was used by 1.8%. Contraceptive use by women in legal and consensual marriages is far higher than use by others because they represent the majority of sexually active wom- en, have greater frequency of intercourse, and have higher fertility and risk of unplanned pregnancies. In Georgia, virtually all users of contraceptive methods are married, and currently 53% of married women are currently using contraception, including 35% who were using modern methods. In contrast, use among those previously married is 6% and among those nev- er married almost nonexistent. Virtually all previously married users employ modern methods (4% using condoms and 2% using long term or permanent meth- ods of the IUD or tubal ligation). These results may be explained by several factors. First, extramarital intercourse in Georgia is rare or de- nied by the majority of women as it is not acceptable by society. So unmarried women may deny not only use of contraception but also having sex at all. (Indi- rect evidence of this is in the male survey ). Also, many women even subconsciously do not consider condom use by men as contraceptive use by themselves. And finally the higher figure of condom use reported by men than by women may be partially explained by a sharper physical memory by the male from using the method. All of these factors can help explain the dif- ferences between results obtained from the Male and Ever-use of Specific Contraceptive Methods (%) Among All Women Aged 15-44:1999, 2005 and 2010 Figure 8.1.4 1999 2005 2010 Rhythm Method IUD Condoms Female Sterilization Withdrawal Oral Contraceptives 17 17 18 12 17 15 14 14 16 10 13 20 6 8 10 1 1 2 Current Use of Specific Contraceptive Methods by Marital Status Figure 8.2.1 Currently married Previously married Never married Total 21 11 68 35 18 47 6 64 100 No method Modern method Traditional method REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 142 Women surveys, conducted nearly at the same time (2005): current use of modern methods as reported by men was 39.5% but by women only 27% due largely to differences for condom use: men 29% and women 5%. Usage of other methods by males is just 10%. Despite the recent increase in current contraceptive use—from 41% in 1999 to 53% in 2010—Georgia con- tinues to have one of the lowest contraceptive preva- lence rates (CPR) in Eastern Europe and Eurasia (Fig- ure 8.2.2). In many Eastern European countries (i.e. Albania, Mol- dova, Russia, and Ukraine), around two-thirds of cou- ples are using contraceptives, compared to Georgia’s latest rate of 53%. The CPR in Georgia is comparable to the rates in Armenia in 2005 (54% of married wom- en) and Azerbaijan in 2006 (51% of married women), but the prevalence of modern methods is twice as high in Georgia. The use of modern methods in 2010 was comparable to the corresponding rate in Romania in 2004 (34%) but lower than the most recent avail- able rates in Moldova, Ukraine, Russia, and Central Asia. The use of traditional methods in Georgia (19%) was higher in 2010 than in the Central Asian countries (ranging from 4% to 9%) and comparable to the rates in Ukraine and Russia. Table 8.2.2 shows current use of modern and tradi- tional contraception among married women aged 15– 44, according to residence and region. As expected, urban women were more likely than their rural coun- terparts to be current users of contraceptives. In the urban areas, condoms were the most commonly used Current Contraceptive Prevalence Among Married Women Aged 15–44;Selected Countries in Eastern Europe and Eurasia Figure 8.2.2 Modern Traditional 80 70 60 50 40 30 20 10 0 AL CZ MD RO RU UA AM AZ GE99 Ge05 Ge10 KZ KG TM UZ Percentage 11 43 44 34 53 20 14 20 48 26 35 55 50 47 5358 26 24 20 19 34 37 21 21 24 19 8 9 8 4 Eastern Europe Caucasus Central Asia Source: Most recent RHS or DHS survey in AL=Albania, 2008; CZ=Czech Rep., 1993; MD=Moldova, 2005; RO=Romania, 2004; RU=Russia, 1999; UA=Ukraine, 2007; AM=Armenia 2005; AZ=Azerbaijan 2006; GE=Georgia, 1999, 2005, 2010; KZ=Kazakhstan, 1999; KG=Kyrgyz Republic, 1997 TM=Turkmenistan, 2000; UZ=Uzbekistan., 1996. * Abkhazia: Autonomous region not under goverment control Current Use of Any Contraception by RegionFigure 8.2.3 Current Contraceptive Use (% Married Women) <45 45-49 50-54 55-59 60+ * FINAL REPORT 143 method of contraception, surpassing rural use by 2.5 times. Use of any method varied substantially by region, from lows of 44%-45% in Adjara and Mtskheta-Mtianeti to 61% in Tbilisi and Shida Kartli (Figure 8.2.3). Modern method use was especially high in Tbilisi at 46% (Ta- ble 8.2.2 and Figure 8.2.4). Excepting the regions of Samtskhe-Jahakheti and Adjara, couples in all other regions were more likely to use modern methods over traditional methods. The most commonly used methods in most regions were the condom and IUD. Condom use was highest in Tbilisi (25%) and lowest in Adjara (5%). IUD use was highest in Shida Kartli, Samegrelo and Imereti (15%– 16%). Use of oral contraceptives ranged from 1% in Samtskhe-Jahakheti to 9% in Samegrelo. Withdrawal was most common in the Samtskhe-Jahakheti and Ad- jara regions (27% and 20%, respectively). As shown in Table 8.2.3 and Figure 8.2.5, the highest rates of marital contraceptive use were among wom- en aged 30–34, women with two children, women with a university-level education, and women of high socioeconomic status. Notably, women in each of these groups were more likely to be using a modern method of contraception than a traditional method. Childlessness and young adult age (15–24 years) were associated with the lowest contraceptive prevalence and lowest use of modern methods among married women. The use of any method increased substan- tially with the number of living children, from a low of 6% among childless women to over 60% among women with two or more children. Use of any method * Abkhazia: Autonomous region not under goverment control Current Use of Modern Contraception, by RegionFigure 8.2.4 Current Modern Contraceptive Use (% Married Women) <25 25-29 30-34 35-39 40+ * Current Use of Modern and Traditional Contraceptive Methods by Selected Characteristics Among Married Women Aged 15–44 Figure 8.2.5 Total Residence Urban Rural Education <12 12 Complete Technicum University Age Group 15-24 25-34 35-44 Modern Methods Traditional Methods 35 42 28 28 32 26 44 28 39 34 19 15 22 21 16 22 17 11 19 26 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 144 of contraception was slightly higher among Georgian women than among women of other ethnic back- grounds. The use of modern contraceptive methods was at least 50% higher among Georgians than among Azeri and Armenian women (37% vs. 23% and 20%, respectively). The percentage of married women aged 15–44 years who were using contraception increased from 41% in 1999 to 45% in 2005 and 53% in 2010 (Table 8.2.4 and Figure 8.2.6). The use of modern contraceptive meth- ods increased from 20% to 35% (a 75% increase). After 1999 the prevalence of modern methods exceeded the prevalence of traditional methods. As document- ed by the U.N., the adoption of modern methods of contraception in Georgia occurred at a much faster pace than elsewhere. In Figure 8.2.7, use of modern methods in Georgia increased by 75% (gain of 15% on base of 20%) compared to only 33% (gain of 12% on base of 36%) for the Eastern European region. At the same time, the world average remained unchanged. According to the official Georgia figures for the pop- ulation distribution by age and sex, the increase in modern contraceptive users after 1999 means that in 2010 there are almost 67,000 more women employing modern methods of contraception than there were in 1999. Such increases will mount year by year, with im- portant implications for contraceptive forecasting and prevention of supply shortfalls, particularly at a time when donated contraceptive supplies are decreasing. Drawing upon the information in Table 8.2.2, Table 8.2.3, and Figure 8.2.8, differences in use can be de- scribed by method, for numerous subgroups of the population. There is an overall preference for condom use (14%), IUD (13%) and withdrawal (11%). Condom prevalence was much higher among urban than rural couples (20% vs. 8%) and it increased directly with ed- ucation (from 7% of women with less than completed education to 21% of those with a university education) and with socioeconomic status (SES) of the household (from 7% of women living in low-SES households to 20% of women in high-SES households). Trends in Current Use of Contraception Among Married Women Aged 15-44: 1999, 2005 and 2010 Figure 8.2.6 1999 60 50 40 30 20 10 0 41 21 2005 2010 20 21 26 47 53 19 35 Any Method Traditional Method Modern Method Trends in Current Use of Modern Contraception in Georgia Compared to Eastern Europe and World Average Figure 8.2.7 1999 41 36 2005 2010 55 Georgia Eastern Europe World Percentage of Married Women Using Modern Contraception 26 56 35 48 56 Source: UN Department of Economics and Social Affairs, Population Division: World Contraceptive Use, 2010; SSSR Vestnik Statiski, 1991; GERHS 1999, 2005 and 2010. FINAL REPORT 145 The only other modern method commonly used was the IUD; for which use was highest at 16% in Shida Kartli and 15% in Samegrelo and Imereti. IUD use in- creased somewhat though irregularly with age and number of living children. Use of withdrawal, the third most prevalent contraceptive method, was associated with rural residence (15%), incomplete secondary ed- ucation (17%), low wealth quintile (18%), having two or more children (14%–15%) and being of Armenian or Azeri descent (26% and 20%, respectively). Pop- ularity of withdrawal among Armenians was found also in the adolescent survey co-funded by the EU and UNFPA (RHIYC Project) in 2009 . That compara- tive analysis of results from Adolescent Reproductive Health Surveys conducted in Armenia, Azerbaijan, and Georgia showed that both awareness and knowledge of withdrawal were highest among Armenian ado- lescents (96% and 95% respectively) and much less among Azeri (14% and 12%) and Georgian (35% and 10%) adolescents. Prevalence of hormonal contraception remained low across all subgroups. The highest prevalence was re- ported by women in Samegrelo and Kakheti, probably due to recent regional family planning activities fo- cused on increased used of hormonal methods, with support from donors. There was also an extremely low prevalence (3%) and lack of interest in tubal liga- tion, despite the fact that most married and fecund respondents reported that they wanted no more chil- dren. This is likely rooted in the lack of information about the method among family planning clients, as well as negative providers’ attitudes, and limited pro- vider training in modern sterilization techniques (i.e. mini-laparotomy for female sterilization and simpler vasectomy) (Tsertsvadze et al., 2010). Other modern methods (such as injectables, spermicides, and the diaphragm) were seldom used. Data collected in the previous survey rounds in Geor- gia demonstrated a heavy reliance on traditional Current Use of Modern and Traditional Contraceptive Methods by Selected Characteristics Among Married Women Aged 15–44 Figure 8.2.8 Total Residence Urban Rural SES Low Middle High No. of Children 0 1 2 3 4+ 14 20 8 7 9 19 4 16 15 13 4 13 13 12 12 12 13 11 16 13 14 4 3 5 4 5 4 4 5 5 3 2 2 1 11 7 15 16 12 9 8 14 15 15 7 8 7 6 7 8 7 9 9 7 Condoms IUD Oral Contraceptives Other Modern Withdrawal Rhythm Method Trends in Contraceptive Prevalence, by Specific Methods among Married Women Aged 15–44 Years; 1999 ,2005 and 2010 Figure 8.2.9 Total 60 50 40 30 20 10 0 1999 2005 2010 40 47 53 10 12 13 11 11 11 10 10 7 6 9 14 1 43 3 22 IUD Withdrawal Rhythm Method Condoms Oral Contraceptives Tubal Ligation REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 146 methods, especially withdrawal. However the 2010 survey showed a substantial increase in the use of modern methods while the use of traditional meth- ods declined. Whereas withdrawal and the rhythm method were the leading methods in 1999, they were the second and third most prevalent methods in 2005 and the third and fourth most prevalent methods in 2010 (Figure 8.2.9). From 1999 to 2010, condom use among couples in- creased 2.5 times (from 6% to 14%) and IUD use in- creased from 10% to 13%, becoming the first and second most used methods, respectively. Recent well-publicized upsurges in the prevalence of sexually transmitted infections and risk of HIV transmission may have contributed to the increase in condom use. The increase in IUD use is probably related to its cost- effectiveness and the desire to limit family size after having the intended number of children. Pill use, still very low, changed only from 3% in 2005 to 4% in 2010. Increased use of condoms, IUDs, and oral contracep- tives was solely responsible for the overall increase in contraceptive prevalence between 2005 and 2010. There were no noticeable changes in the use of other modern methods of contraception. 8.3 Source of contraception Contraceptive supplies in Georgia are not subsidized by the government or by health insurance plans. Even the poorest segment of the population (800,000 per- sons, according to governmental estimates) does not benefit from subsidies for contraceptive services, al- though most other care is covered by the government via private insurance contributions. Through the con- certed efforts of donors, primarily UNFPA and USAID, commodities are made available (either free of charge or for a small fee) in health clinics that provide family planning services. Source of Supply of Modern Contraceptive Methods Among Married Women Aged 15-44: 1999, 2005 and 2010 Figure 8.3.2 1999 2005 2010 Health Sector 55 Pharmacy Other 53 50 37 39 45 8 8 5 Source of Supply for Modern Contraceptive Methods Among Married Women Aged 15–44 Currently Using a Method Figure 8.3.1 IUD Condoms Oral Contraceptives Any Method 21 64 100 Partner Health Facility Pharmacy 3 45 50 1 99 8 87 3 57 38 FINAL REPORT 147 Table 8.3.1 presents the sources of contraception for currently married users of modern methods. The health care facilities were the principal source of modern contraceptives (50%). Commercial sales, spe- cifically through pharmacies, were the second largest source of contraceptive supplies (45%), and “Other” sources covered 5%, to total 100% of all sources. Women’s consultation clinics supplied 25% of contra- ceptive users while the hospital categories supplied 21%. The “Other” category included sources such as partners, friends and relatives, and the open market. Sources varied greatly according to the contraceptive method used. As shown in the bottom panel of the table, the medical sector was virtually the only source for IUDs (99%) and tubal ligation (97%). Pharmacies were the predominant source for methods which re- quire periodic re-supply. They were the principal pro- vider of condoms, supplying more than four fifths of women who reported their partners were using con- doms. Pharmacies were also the leading source for spermicides (89%), other modern methods (73%), and over half of pill users (56%) (Figure 8.3.1). Figure 8.3.2 shows changes in the sources of mod- ern contraceptives between 1999, 2005 and 2010. In general, the changes are small. The participation of the medical sector declined from 55% (1999) to 53% (2005) and 50% (2010), while the participation of pri- vate pharmacies increased from 36% (1999) to 39% (2005) and 45% (2010). It should be noted that sources of contraceptive sup- plies are not completely comparable with the data col- lected in the two previous surveys. In 2007 the Gov- ernment of Georgia launched a comprehensive health care reform aimed at privatization of the system. The privatization of hospitals was regulated in the Hospi- tal Development Master Plan (MoLHSA, Decree #11, Percentage of Women Who Desire to Switch to Another Contraceptive Method by Current Method Among Married Women Aged 15-44 Who Are Currently Using Contraceptives Figure 8.4.1 Oral Contraceptives 17 IUD SpermicidesCondoms 3 31 19 Most Commonly Cited Reasons for Not Currently Using Contraception, by Age Group Among Married Women Aged 15–44 Figure 8.4.2 0% 10% 20% 30% 40% Currently Pregnant Desires Pregnancy Not Currently Sexually Active Female Infecundity Uses Douching Negligence Partner Objects 15-24 25-34 35-44 50% 60% 70% 55 29 7 24 23 13 6 12 16 2 11 37 4 7 12 5 7 6 2 5 5 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 148 January 26, 2007), which called for complete replace- ment of the existing hospital infrastructure by a full transfer of ownership to the private sector. Primary health care services are also in various stages of pri- vatization. The entire privatization process is planned to be completed by the end of 2012 (Chaturidze et al., 2009). 8.4 Desire to Use a Different Contraceptive Method As shown in Table 8.4.1, only 16% of married users of modern methods (230 cases out of 1413) desired to use a different method, implying that 84% preferred their method to the available alternatives. A remark- able difference arose by method: only 3% of IUD users desired a change vs. a full 31% of condom users. Pill users were intermediate at 17% and spermicides at 19%. (Figure 8.4.1). The most frequently cited reasons (not shown) women gave for dissatisfaction with their current method included inconvenience, low effec- tiveness/method failure resulting in pregnancy, and proneness to forgetfulness. The popularity of the IUD is reflected in the IUD col- umn of Table 8.4.1, which shows it to be the most de- sired method among women who desired to switch methods (68%). Few women wanted to switch to tu- bal ligation (13%), pills (10%), or condoms (3%). No one wanted to change to the injectable, which is little known or available in Georgia. The desire to change to the IUD was especially high in the lowest wealth quintile. It declined at older ages but was irregular with number of children. However the desire to use female sterilization rose sharply with number of children, reflecting an urgency for a reli- able method to cease childbearing. Rural women also chose sterilization more than urban women. Nearly 77% of married women who were not using contraception at the time of the survey cited reasons related to pregnancy, fertility, or sexual activity. Most were currently pregnant (27%), desired pregnancy (20%), were infertile for medical (non contraceptive) or menopausal (19%) reasons, or had not had inter- course recently (12%). Additionally, 18% of the wom- en gave “other” reasons for not using contraception at the time of the survey. Nearly 8% of women said they were using vaginal douching to avoid pregnancy, while another 6% declared that they just did not think about using a contraceptive method. Only 4% of the women stated that their husbands or partners objected to the use of contraception. These averages are shown by age in Figure 8.4.2. (Between 1999 and 2010 the per- centage of married women who wanted to get preg- nant soon increased by 50%, from 13% to 20%.) Reasons for not using a method differed sharply by age group. Most young adult women were pregnant or seeking to become pregnant (79%), whereas women aged 35–44 years were not able to conceive because of either impaired fecundity (37%) or a lack of recent sexual activity (15%). It is worth mentioning that 13% of women aged 35–44 desired pregnancy, which is al- most a three-fold increase compared to previous sur- veys, when only 4% and 5%, respectively, expressed such intentions. 8.5 Users of Traditional Methods Of all current users of contraceptive methods, about a third (34%) use a traditional method, such as rhythm and/or withdrawal, which are the third and fourth most used of any contraceptive methods in Georgia. Among the various reasons that traditional users gave for preferring their methods to the alternative of mod- Most Important Reasons for Not Using Modern Contraceptives Among Women Aged 15-44 Currently Using Traditional Methods: 1999, 2005 and 2010 Figure 8.5.1 0% 20% 40% 60% 80% 100% Religious Belief Doctor’s Recommendation Another Person’s Advice Difficult to Get Partner Preference Cost Lack of Knowledge Fear of Side Effects 2010 2005 1999 53 50 23 45 53 32 40 43 39 51 50 42 67 64 49 75 75 67 67 78 70 90 93 87 FINAL REPORT 149 ern methods, many cited fear of health problems or side effects associated with them. Others cited lack of knowledge about other methods; cost or poor avail- ability of the methods; partner preferences; medical or other persons’ advice against modern methods; and religious beliefs. About 90% of respondents mentioned that fear of, or experience with, side effects from modern meth- ods was an important or somewhat important factor (Table 8.5.1). Nearly 67% stated that they possessed little knowledge of modern methods, indicating the need for an information and education program on the advantages and disadvantages of using modern contraceptive methods. (Note that respondents could name multiple reasons, so they sum to over 100% in the table). Cost was a factor for 75% of the respondents for not using a modern method, suggesting that the availa- bility of subsidized contraception may help eliminate an important barrier to the use of modern methods. Difficulty in getting a modern method was mentioned by half (51%) of the users of traditional methods. This finding has programmatic implications in that it indicates that the geographic availability of modern methods in Georgia is not evenly distributed. A doc- tor’s recommendation was a reason given by 45% of the women as to why they were using a traditional method, which suggests that modern methods may not always be brought up during the doctor-patient dialogue and that physicians may need professional updates on modern methods. The husband’s or partner’s choice was given as a rea- son by 67% of respondents, indicating that informa- tion and education programs should focus on men as well as women. Religious beliefs were important or somewhat important for 53% of these traditional method users. Regarding subgroup differences, lack of knowledge of modern methods was a commonly cited reason for use of traditional methods among rural women, women aged 15-24 years, women with two children, women with a secondary or less education, and Arme- nian women. Similarly, the cost of modern methods was mentioned more often by rural women, as well as by women of least education and the lowest wealth quintile. Difficulty in getting a modern method was more frequently mentioned by women with least ac- cess to services in general: rural and low education women, and those in the low wealth quintiles, along with Armenian and Azeri women. Notably, nearly 50% of women aged 15-24 stated that they were using a traditional method on their doctor’s recommenda- tion; this is the same age group that mentioned lack of knowledge of modern methods as a reason for use of traditional methods. This suggests a need for doc- tors to talk to young women about the full range of contraceptive choices available to them. Similar reasons for not using modern methods were cited by users of traditional methods in the 1999 and 2005 surveys (Figure 8.5.1). From 1999 to 2010, more women cited cost (from 67% to 75%), partner’s pref- erence (from 49% to 67%), religious beliefs (from 23% to 53%), doctor’s recommendations (from 32% to 45%), and difficulty in getting a modern method (42% to 51%), as important reasons for not using modern contraceptives. Users of traditional methods considered their cur- rent method more effective (29%) or equally effec- tive (46%), compared with modern methods (Table 8.5.2). These are the same proportions as in 1999 and Most Commonly Cited Reasons for Not Currently Using Contraception, by Age Group among Married Women Aged 15–44 Figure 8.6.1 0% 10% 20% 30% 40% Currently Pregnant Desires Pregnancy Not Currently Sexually Active Female Infecundity Uses Douching Negligence Partner Objects 15-24 25-34 35-44 50% 60% 70% 55 29 7 24 23 13 6 12 16 2 11 37 4 7 12 5 7 6 2 5 5 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 150 2005. A response of “more effective” was given espe- cially by women aged 35-44, women with secondary or less education, Georgian ethnicity, and women in the fourth highest wealth quintile. On the other hand, 16% considered their current method to be less ef- fective than a modern method, and this did not vary much across the variables shown in Table 8.5.2, with the exceptions of the lower figures for the “other ur- ban” group and the two top wealth quintiles, and the high figures for women with two children and Azeri women. About 9% of respondents did not know or were un- sure whether their current method was more or less effective than a modern method; this was much high- er among the low education group and both Azeri and Armenian women, and tended to be higher at the lower wealth quintiles. 8.6 Reasons for Not Using Contraception As shown in Table 8.6.1, nearly 77% of married wom- en who were not using contraception at the time of the survey cited reasons related to pregnancy, fertility, or sexual activity. Most who were not using contra- ception were currently pregnant (27%), desired preg- nancy (20%), were infertile for medical (non contra- ceptive) or menopausal (19%) reasons, or had not had intercourse recently (12%) (not shown). Additionally, almost 23% of the women gave “Other” reasons for not using contraception. Nearly 8% said they were using vaginal douching to avoid pregnancy, while an- other 6% declared that they just did not think about using a contraceptive method. Only 4% of the women stated that their husbands or partners objected to the use of contraception. Table 8.6.1 shows the differences according to person- al characteristics. The percent giving reasons relating to pregnancy, fertility, or sexual activity was higher in urban than in rural areas, declined with age and num- ber of children, but rose with education and wealth quintiles. It was very low in the Azeri group. All these patterns were reversed for “Other” reasons since the two totaled nearly 100% for each group. Between 1999 and 2010 the percentage of all nonus- ers who wanted to get pregnant increased by about half, from 13% to 20%. Reasons for not using a method differed sharply by age group (Figure 8.6.1). Most young adult women were pregnant or seeking to become pregnant (79%), whereas women aged 35–44 years were not able to conceive because of either impaired fecundity (37%) or a lack of recent sexual activity (16%). It is worth mentioning that 13% of women aged 35–44 desired pregnancy, which is almost a three-fold increase com- pared to 1999 and 2005, when only 4% and 5%, re- spectively, expressed that intention. 8.7 Intention to Use Contraceptives Among Non-users As Table 8.7.1 shows, 30% of married respondents aged 15-44 who were not using any contraceptive method at the time of the survey said they planned to use a method in the next 12 months, while 17% planned to use a method sometime later. Thus, 47% plan to use a method, which is 9% higher than in 1999. As shown in Figure 8.7.1, planning to use a method in the next 12 months varied according to re- gion, and was highest in the Adjara region and lowest in the Kvemo Kartli and Samtskhe-Javakheti regions. Interestingly, about 22% of respondents were unde- cided as to whether they will use contraceptives in the Intention to Use Contraception in the Next 12 Month Among Married Fecund Women Who Are Not Currently Using a Method, by Region Figure 8.7.1 Racha-Svaneti Mtskheta-Mtianeti Imereti Samegrelo Guria Adjara Samtskhe-Javakheti Kvemo Kartli Shida Kartli Kakheti Tbilisi 24 32 33 27 26 41 22 22 29 32 30 FINAL REPORT 151 future, while a full third (32%) declared that they do not plan to use a method at any time. That is high- est among women aged 35-44 years and women with three or more children (who include more infecund and sexually inactive women), and Azeri women. In fact the desire to use a method in the next 12 months or at some point in the future was inversely associated with age and number of living children. Over three times more respondents aged 15-24 (72%) planned to use a method in the next 12 months or lat- er than those aged 35-44 (21%). The percent planning to use fell regularly with the number of children from 50%-51% for 0-1 child to 44% for 2 children to only 37% for 3+ children. Further, for both age and number of children there was a decided shift toward using in the next 12 months rather than later, as age rose and number of children increased. These data suggest that the family planning program in Georgia should focus more promotion efforts on younger women and those with two or fewer children. Among fecund married respondents who planned to use contraception in the future, the vast majority desired to use a modern method (Table 8.7.2). The method most desired was the IUD (47%), followed by condoms (14%), and pills (13%). An additional 3% preferred female sterilization. Regarding traditional methods, 6% of respondents planned to use the rhythm method, and 6.5% planned to use withdrawal. Of the non-users who planned to use a modern meth- od in the next 12 months or at some point in the fu- ture, 33% stated that they would obtain their method from a women’s consultation clinic, while 37% would obtain their method from a pharmacy (Table 8.7.3). A women’s consultation clinic is considered the best place to obtain an IUD (50%) but a pharmacy for get- ting pills (78%) and condoms/spermicides (92%). 8.8 Contraceptive Failure and Discontinuation Contraceptive failure rates (i.e., the probability of be- coming pregnant while using a contraceptive method) and discontinuation rates (i.e., the probability of stop- ping use of a contraceptive method for any reason, including getting pregnant) were calculated using information collected through the detailed month- by-month pregnancy and contraceptive use histories (Table 8.8.1). The estimates should be considered conservative because some women may have not reported pregnancies that ended in abortions and if they were using contraceptives at the time of con- ception, the corresponding method failure would not have been captured from their histories; thus, the true rates are probably somewhat higher than those shown in the table. Monthly probabilities of failure and of discontinu- ing contraceptive use for all respondents who used a contraceptive method during the observed period were estimated using life table analysis. Linking these monthly probabilities, 12-, 24-, and 36-month contra- ceptive failure and discontinuation rates were calcu- lated. These rates represent the proportion of users who stopped using their method within the first year, second year, or third year of use for any reason (the discontinuation rate) or because they became preg- nant while using the method (the failure rate). The 12-, 24-, and 36-month intervals of use refer to un- interrupted use; a new interval starts when a woman begins to use a method for the first time or when she resumes its use after a period during which she had used another method or no method. Because only the use of a single method can be evaluated during any month, the more effective of two methods if used dur- ing the same month was recorded. An estimated 10% of respondents became pregnant during the first year of using a method, 17% became Preferred Method of Contraception Among Fecund Married Women Aged 15-44 Who Are Not Currently Using Contraception and Desire to Use in the Future Figure 8.7.2 Oral Contraceptives 47 IUD Female sterilization Condoms 13 14 3 13 Traditional Method REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 152 pregnant within 2 years, and 22% became pregnant within 3 years. Failure rates varied by type of contra- ceptive method - the IUD had the lowest failure rate at 1, 2, and 3 years: between 0.9% and 2.9% of IUD us- ers became pregnant. Condom users reported failure rates of 5% during the first year, 10% within 2 years, and 14% within 3 years. Pill users reported failure rates of 7% during the first year, 10% within 2 years, and 16% within 3 years. The highest failure rates at 12, 24, and 36 months of use were reported by users of the rhythm method (21%, 33%, and 41%, respective- ly) and withdrawal (18%, 30%, and 37%, respectively), which highlights the need for increased information, education, and counseling efforts to promote correct use of more effective contraceptive methods. Overall, 35% of respondents discontinued their meth- od within 1 year, 53% within 2 years, and 64% within 3 years of use. The IUD was the only method with a low discontinuation rate at 1 year (9%), but 30% of IUD us- ers had stopped using the method within 3 years (the lowest among all methods). Only 11% of IUD users (0.9/8.6 in the first year) discontinued the method be- cause of method failure. In contrast, 52% of pill users discontinued their method during the first year and 81% within 3 years, despite the low failure rate of this method. As with the IUD, failure was a small propor- tion of the pill discontinuation rate at 14% during the first year (7.3/52.1). Condom discontinuation shows a similar pattern: 40% used the condom for less than 1 year and 69% for less than 3 years. Method failure accounted for 13% (5.2/40.4) of the reasons cited for condom discontinuation. Withdrawal and the rhythm method were associated with very high discontinu- ation rates at one year (35%-37%), two years (54%- 61%), and 3 years (66%-73%). Method failure was cited as the reason for more than one-half of those discontinuations (50%-57%). Of all those who dis- continued a method, an unknown proportion became accidentally pregnant or switched to an alternative method. In addition to method failure (13%), respondents dis- continued a method for many other reasons (Table 8.8.2): the most cited reasons were desire to become pregnant (10%), partner’s objections or temporary ab- sence (8%), experienced or feared side effects (6%), negligence (4%) and switching to another method (4%). Note that the table gives “net” rates in the Total row but “gross” rates for all other rows, for the indi- vidual reasons. The main reason for discontinuation varied greatly with type of contraceptive method. The IUD discontin- uation rate in the first year of use, the lowest among all contraceptive methods, was heavily influenced by side effects or health concerns associated with the method. The experience or fear of side effects was also a principal reason for discontinuing use of pill. Women whose partners were using condoms discon- tinued use mainly because of partners’ objections or absence. Method failure was by far the most impor- tant reason for discontinuation of withdrawal and the rhythm method. FINAL REPORT 153 Table 8.1.1 Contraceptive Use Status Among All Women Aged 15-44 By Selected Characteristics Reproductive Health Survey: Georgia, 2010 Never Used Previous User Current User Total 53.5 14.5 32.0 100.0 6,292 Residence Urban 53.3 14.9 31.8 100.0 2,975 Rural 53.7 14.1 32.2 100.0 3,317 Region Kakheti 52.4 15.2 32.4 100.0 498 Tbilisi 51.9 16.2 31.9 100.0 1,426 Shida Kartli 50.3 11.6 38.1 100.0 392 Kvemo Kartli 55.3 13.1 31.6 100.0 546 Samtskhe–Javakheti 53.1 12.9 34.0 100.0 481 Adjara 55.8 15.3 29.0 100.0 419 Guria 54.8 11.2 34.0 100.0 401 Samegrelo 54.5 12.4 33.1 100.0 477 Imereti 54.5 14.7 30.7 100.0 805 Mtskheta–Mtianeti 53.6 17.9 28.5 100.0 393 Racha–Svaneti 58.3 11.5 30.2 100.0 454 Marital Status Legally married 27.1 19.4 53.5 100.0 4,011 Consensual union 41.8 10.3 47.9 100.0 87 Previously married 45.6 48.1 6.3 100.0 389 Never married 99.9 0.1 0.0 100.0 1,805 Age Group 15–19 96.5 1.4 2.2 100.0 861 20–24 71.1 8.0 20.9 100.0 1,099 25–29 49.1 12.2 38.7 100.0 1,191 30–34 32.5 19.0 48.5 100.0 1,168 35–39 30.1 21.6 48.2 100.0 1,051 40–44 31.3 29.3 39.4 100.0 922 Number of Living Children 0 97.0 1.9 1.1 100.0 2,276 1 36.0 23.4 40.6 100.0 1,286 2 17.3 22.1 60.6 100.0 2,069 3 or more 14.3 27.2 58.5 100.0 661 Education Level Secondary incomplete or less 66.4 10.0 23.6 100.0 1,330 Secondary complete 54.1 14.5 31.4 100.0 1,568 Technicum 44.3 21.0 34.7 100.0 903 University/postgraduate 48.8 15.0 36.2 100.0 2,491 Wealth Quintile Lowest 55.6 14.8 29.6 100.0 1,093 Second 53.8 13.6 32.6 100.0 1,385 Middle 53.2 13.2 33.5 100.0 1,413 Fourth 59.2 13.3 27.5 100.0 1,037 Highest 48.2 17.0 34.8 100.0 1,364 Ethnicity Georgian 53.3 14.6 32.1 100.0 5,488 Azeri 54.0 13.6 32.4 100.0 276 Armenian 55.2 14.7 30.1 100.0 364 Other 54.5 14.7 30.9 100.0 164 Characteristic Contraceptive Status Total No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 154 Table 8.1.2 Ever–Use of Contraceptive Methods by Type of Method Used Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Any Method Any Modern Method Any Traditional Method Total 46.5 36.3 25.5 6,292 Residence Urban 46.9 39.7 22.9 2,975 Rural 46.1 32.6 28.4 3,317 Region Kakheti 47.3 38.6 26.4 498 Tbilisi 48.2 42.2 23.9 1,426 Shida Kartli 49.3 37.5 27.2 392 Kvemo Kartli 44.7 30.3 28.4 546 Samtskhe–Javakheti 46.7 26.9 39.3 481 Adjara 44.2 26.5 25.6 419 Guria 45.6 31.8 27.4 401 Samegrelo 45.9 40.0 19.2 477 Imereti 45.7 37.1 23.3 805 Mtskheta–Mtianeti 46.0 37.6 26.2 393 Racha–Svaneti 41.0 28.8 26.8 454 Marital Status Legally married 72.7 56.5 40.3 4,011 Consensual union 57.1 44.7 30.8 87 Previously married 53.8 44.5 26.8 389 Never married 0.6 0.5 0.1 1,805 Age Group 15–19 3.6 3.1 0.7 861 20–24 29.3 23.5 11.4 1,099 25–29 51.0 39.7 25.2 1,191 30–34 67.4 55.1 37.0 1,168 35–39 69.6 53.5 43.8 1,051 40–44 68.5 50.7 41.9 922 Number of Living Children 0 3.3 3.0 0.8 2,276 1 63.8 50.6 29.0 1,286 2 82.5 64.7 48.3 2,069 3 or more 85.7 62.6 53.0 661 Education Level Secondary incomplete or less 33.7 23.3 18.3 1,330 Secondary complete 45.9 32.7 26.5 1,568 Technicum 55.6 43.0 32.5 903 University/postgraduate 51.2 43.9 26.6 2,491 Wealth Quintile Lowest 44.4 27.2 30.1 1,093 Second 45.8 32.7 26.7 1,385 Middle 46.8 37.5 25.3 1,413 Fourth 41.3 32.7 21.4 1,037 Highest 51.7 45.8 25.0 1,364 Ethnicity Georgian 46.7 37.5 24.7 5,488 Azeri 45.8 26.3 29.1 276 Armenian 44.8 25.6 35.3 364 Other 45.5 37.5 24.2 164 Characteristic Contraceptive Status No. of Cases FINAL REPORT 155 Ta bl e 8 .1. 3 Ev er –U se o f C on tra ce pt ive M et ho ds b y M et ho d an d Ag e G ro up A m on g Al l W om en A ge d 15 –4 4 Re pr od uc tiv e H ea lth S ur ve y: G eo rg ia, 20 10 Co nd om Ca len da r (R hy th m ) Me th od IU D W ith dr aw al Pi ll Sp er m ici de s Tu ba l Li ga tio n Em er ge nc y Co nt ra ce pt io n In jec ta bl es Va se ct om y 15 –1 9 2.0 0.3 0.7 0.5 0.8 0.2 0.0 0.0 0.0 0.0 86 1 20 –2 4 13 .9 5.9 7.0 7.3 6.1 1.7 0.3 0.2 0.1 0.0 1,0 99 25 –2 9 21 .3 14 .9 15 .6 15 .8 11 .1 3.6 0.9 0.0 0.0 0.1 1,1 91 30 –3 4 30 .6 24 .1 23 .0 19 .9 17 .5 6.9 2.5 0.6 0.4 0.0 1,1 68 35 –3 9 29 .3 30 .6 25 .4 26 .1 15 .7 4.8 3.4 0.3 0.5 0.0 1,0 51 40 –4 4 23 .4 30 .5 30 .2 23 .6 12 .7 4.5 4.9 0.6 0.1 0.0 92 2 To ta l 19 .5 16 .8 16 .2 14 .9 10 .3 3.5 1.9 0.3 0.2 0.0 6,2 92 Me th od o f C on tra ce pt io n Ag e G ro up No . o f C as es REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 156 Table 8.2.1 Percent Using Contraception by Marital Status and Method Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Married Previously Married Never Married Any Method 32.0 53.4 6.3 0.0 Modern Methods 20.9 34.7 6.1 0.0 Pill 2.4 4.1 0.3 0.0 IUD 7.5 12.5 0.9 0.0 Condoms 8.3 13.6 3.8 0.0 Spermicides 0.9 1.5 0.0 0.0 Tubal ligation 1.8 2.9 1.1 0.0 Other modern methods 0.0 0.1 0.0 0.0 Traditional Methods 11.0 18.5 0.2 0.0 Calendar (Rhythm) method 4.4 7.4 0.2 0.0 Withdrawal 6.6 11.1 0.0 0.0 Not Currently Using 68.0 46.6 93.7 100.0 Contraceptive Status All Women Marital Status C y U g 68 0 6 6 93 00 0 Total 100.0 100.0 100.0 100.0 No. of Cases 6,292 4,098 389 1,805 Table 8.2.2 Percent Using Modern and Traditional Contraception by Residence and Region Among Married Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Condom IUD Pill Tubal Ligation Other Any Modern Method With- drawal Calendar (Rhythm) Method Any Traditional Method Total 53.4 13.6 12.5 4.1 2.9 1.7 34.8 11.1 7.4 18.6 4,098 Residence Urban 56.9 19.5 13.3 3.4 3.0 2.4 41.5 7.1 8.1 15.3 1,806 Rural 50.0 7.9 11.8 4.7 2.8 1.1 28.2 15.0 6.6 21.7 2,292 Region Kakheti 50.6 11.5 14.5 7.5 1.0 3.0 36.2 6.2 7.0 14.5 348 Tbilisi 60.9 25.4 13.3 2.5 2.0 2.7 46.0 5.9 9.0 14.9 815 Shida Kartli 61.3 13.2 15.8 1.9 3.2 1.9 36.1 10.6 14.5 25.2 266 Kvemo Kartli 48.9 9.5 10.1 2.5 2.3 1.1 25.5 15.1 8.3 23.4 375 Characteristic Traditional Method No. of Cases Any Method Modern Method Kvemo Kartli 48.9 9.5 10.1 2.5 2.3 1.1 25.5 15.1 8.3 23.4 375 Samtskhe– Javakheti 55.6 11.4 7.6 1.3 1.0 0.8 22.1 26.6 6.9 33.5 331 Adjara 44.4 5.0 9.4 3.6 3.6 0.3 21.8 19.8 2.8 22.6 292 Guria 53.5 9.4 9.7 6.0 2.8 1.9 29.9 17.0 6.6 23.6 276 Samegrelo 57.0 12.2 14.8 8.6 6.5 1.2 43.3 9.5 4.2 13.6 302 Imereti 49.0 9.1 14.8 4.7 4.4 1.5 34.4 8.3 6.3 14.6 540 Mtskheta–Mtianet i 44.7 12.0 7.2 7.2 1.8 2.4 30.6 7.5 6.6 14.1 270 Racha–Svaneti 52.3 13.5 10.5 1.5 2.5 0.3 28.3 14.8 9.2 24.0 283 FINAL REPORT 157 Table 8.2.3 Percent Using Modern and Traditional Contraception by Method and Selected Characteristics Among Married Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Condom IUD Pill Tubal Ligation Other Subtotal Modern Withdra wal Calendar (Rhythm) Method Subtotal Tradition al Total 53.4 46.6 13.6 12.5 4.1 2.9 1.7 34.8 11.1 7.4 18.6 4,098 Age Group 15–19 20.4 79.6 6.5 5.3 3.7 0.0 0.7 16.2 2.6 1.5 4.2 124 20–24 42.7 57.3 13.0 11.1 4.3 0.5 1.3 30.2 8.6 4.0 12.5 610 25–29 53.9 46.1 16.9 12.7 5.3 1.3 1.7 37.9 10.2 5.8 16.0 863 30–34 61.0 39.0 15.8 12.9 5.2 3.0 2.7 39.4 11.9 9.5 21.6 948 35–39 59.8 40.2 12.5 14.5 3.8 3.8 1.6 36.0 14.5 9.2 23.8 836 40–44 51.3 48.7 10.6 12.1 1.7 6.2 1.5 31.8 11.0 8.3 19.4 717 Number of Living Children 0 5.8 94.2 3.5 0.3 0.4 0.0 0.5 4.7 0.3 0.8 1.1 409 1 47.4 52.6 15.8 11.2 4.2 0.3 1.5 33.0 7.6 6.8 14.5 1,106 2 64.0 36.0 15.4 15.8 4.6 3.4 2.1 41.1 14.0 8.7 22.9 1,956 3 or more 61.7 38.3 11.0 12.8 4.6 7.8 1.8 37.9 15.4 8.3 23.7 627 Education Level Secondary incomplete or 50.7 49.3 4.7 15.4 5.0 2.2 1.1 28.4 17.0 5.3 22.3 726 Secondary 47.7 52.3 9.3 10.0 4.9 2.8 0.9 27.8 13.5 6.3 19.9 1,119 Technicum 48.4 51.6 12.7 9.6 2.8 4.9 2.4 32.2 7.7 8.4 16.2 673 University/ postgraduate 60.5 39.5 20.9 14.2 3.7 2.5 2.4 43.5 8.3 8.5 17.0 1,580 Wealth Quintile Lowest 46.7 53.3 5.6 10.5 4.4 1.9 0.4 23.0 17.5 6.2 23.7 727 Second 50.4 49.6 7.8 13.3 4.4 2.4 1.0 28.6 14.1 7.5 21.9 966 Middle 53.8 46.2 11.3 12.4 5.5 4.4 2.1 35.6 11.5 6.6 18.3 952 Fourth 51.0 49.0 14.5 10.7 3.7 2.6 3.0 34.4 8.4 8.1 16.6 623 Highest 61.4 38.6 25.3 14.5 2.6 2.9 2.0 47.3 6.0 8.1 14.1 830 Ethnicity Georgian 54.3 45.7 14.6 13.1 4.0 3.2 1.8 36.5 9.8 8.0 17.9 3,521 Azeri 44.9 55.1 0.8 14.0 6.5 1.7 0.0 23.0 19.8 2.1 21.8 219 Armenian 50.7 49.3 11.4 4.5 1.0 1.6 2.0 20.4 25.8 4.4 30.2 249 Other 48.0 52.0 15.4 7.7 8.0 0.9 3.8 35.9 6.8 5.3 12.1 109 No. of CasesCharacteristic Any Method Not Using Traditional MethodsModern Methods REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 158 Table 8.2.4 Percent Using Contraceptive Use by Year and Method Among Married Women Aged 15–44 Reproductive Health Surveys: Georgia, 1999, 2005 and 2010 1999 2005 2010 Any Method 40.5 47.3 53.4 Modern Methods 19.8 26.6 34.7 Pill 1.0 3.2 4.1 IUD 9.7 11.6 12.5 Condom 6.3 8.7 13.6 Spermicides 0.1 0.9 1.5 Tubal Ligation 1.6 2.2 2.9 Injectables 0.0 0.0 0.0 Other modern methods 1.0 0.0 0.1 Traditional Methods 20.7 20.7 18.5 Calendar (Rhythm) method 10.2 9.5 7.4 Withdrawal 10.5 11.2 11.1 Not Currently Using 59.5 52.7 46.6 No. of Cases 5,177 4,119 4,098 Contraceptive Status Survey Year FINAL REPORT 159 Ta bl e 8 .3. 1 So ur ce o f S up pl y f or M od er n Me th od s b y S ele ct ed C ha ra ct er ist ics A m on g Ma rri ed W om en A ge d 15 –4 4 W ho A re C ur re nt ly Us in g Mo de rn M et ho ds Re pr od uc tiv e H ea lth S ur ve y: G eo rg ia, 20 10 Ph ar m ac y Su bt ot al He alt h Se ct or W om en 's Co ns ul ta tio n Cl in ic Ci ty H os pi ta l Re gi on al Ho sp ita l Pr im ar y He alt h Ca re Cl in ic/ Ce nt er Re fe rra l Ho sp ita l Mo bi le Cl in ic Su bt ot al Ot he r Pa rtn er / Hu sb an d Fr ien d Re lat ive Op en M ar ke t Ot he r Do es N ot Kn ow To ta l 50 .0 24 .6 11 .6 9.1 4.0 0.6 0.2 44 .8 5.2 3.3 0.4 0.3 0.2 1.0 0.0 10 0.0 1,4 13 Re sid en ce Tb ilis i 34 .7 23 .5 6.8 0.5 1.8 1.6 0.5 59 .8 5.5 4.6 0.7 0.0 0.0 0.2 0.0 10 0.0 37 9 Ot he r U rb an 51 .9 32 .1 11 .5 5.2 2.8 0.2 0.0 44 .2 3.9 2.9 0.2 0.2 0.0 0.5 0.0 10 0.0 37 3 Ru ra l 60 .4 20 .4 15 .2 18 .2 6.4 0.1 0.1 33 .7 6.0 2.6 0.3 0.6 0.6 1.9 0.1 10 0.0 66 1 Ag e G ro up 15 –2 4 43 .8 24 .2 12 .3 4.5 2.8 0.0 0.0 48 .3 8.0 5.6 0.0 0.9 0.0 1.3 0.3 10 0.0 21 1 25 –3 4 46 .2 22 .6 9.1 7.8 5.5 1.0 0.3 49 .8 3.9 3.1 0.3 0.3 0.0 0.3 0.0 10 0.0 68 7 35 –4 4 56 .8 27 .1 14 .2 12 .4 2.6 0.4 0.1 37 .5 5.7 2.6 0.6 0.1 0.6 1.8 0.0 10 0.0 51 5 Ed uc at io n Le ve l Se co nd ar y i nc om ple te or le ss 70 .0 31 .1 9.2 22 .5 6.8 0.0 0.4 26 .2 3.8 1.1 0.0 0.5 0.0 2.3 0.0 10 0.0 19 9 Se co nd ar y c om ple te 52 .6 24 .5 12 .9 9.7 3.9 1.3 0.3 40 .6 6.8 3.6 0.0 0.2 1.0 1.7 0.2 10 0.0 32 4 Te ch nic um 49 .2 18 .7 15 .4 11 .8 3.3 0.0 0.0 46 .0 4.8 3.9 0.4 0.4 0.0 0.0 0.0 10 0.0 20 8 Un ive rsi ty/ po stg ra du ate 43 .2 24 .4 10 .5 4.0 3.3 0.7 0.1 51 .7 5.1 3.6 0.6 0.3 0.0 0.6 0.0 10 0.0 68 2 W ea lth Q ui nt ile Lo we st 58 .7 22 .0 9.8 22 .0 5.0 0.0 0.0 30 .8 10 .4 1.9 0.6 1.8 2.2 3.8 0.0 10 0.0 16 8 Se co nd 62 .4 23 .8 12 .5 19 .8 5.9 0.0 0.3 32 .8 4.9 3.4 0.2 0.4 0.0 1.0 0.0 10 0.0 28 4 Mi dd le 56 .3 22 .2 15 .8 12 .5 5.7 0.0 0.0 39 .3 4.5 3.0 0.3 0.0 0.0 0.9 0.2 10 0.0 33 6 Fo ur th 45 .8 28 .5 10 .2 2.7 3.8 0.5 0.0 50 .5 3.7 2.4 0.0 0.4 0.0 0.9 0.0 10 0.0 22 7 Hi gh es t 38 .4 25 .4 9.3 0.2 1.5 1.6 0.4 56 .4 5.1 4.3 0.7 0.0 0.0 0.2 0.0 10 0.0 39 8 Et hn ici ty Ge or gia n 49 .6 25 .0 11 .6 8.6 3.6 0.7 0.2 45 .5 4.9 3.1 0.3 0.4 0.3 0.8 0.0 10 0.0 1,2 74 Az er i 82 .9 28 .6 15 .9 23 .4 15 .0 0.0 0.0 10 .2 6.8 0.0 0.0 0.0 0.0 6.8 0.0 10 0.0 52 Ar me nia n 29 .9 15 .4 9.3 5.2 0.0 0.0 0.0 58 .8 11 .3 10 .0 0.0 0.0 0.0 0.0 1.3 10 0.0 45 Ot he r 34 .0 14 .5 7.4 6.8 3.5 0.0 1.7 58 .8 7.2 4.8 2.4 0.0 0.0 0.0 0.0 10 0.0 42 Mo de rn M et ho d Us ed * Pi ll 37 .5 15 .9 5.1 5.7 10 .7 0.0 0.0 56 .3 6.2 0.0 0.6 1.2 0.0 4.4 0.0 10 0.0 17 6 IU D 99 .0 60 .0 14 .5 18 .2 5.2 1.1 0.0 0.4 0.6 0.0 0.0 0.2 0.0 0.4 0.0 10 0.0 49 8 Co nd om s 3.2 1.4 0.2 0.0 1.1 0.0 0.5 86 .7 10 .1 8.4 0.6 0.3 0.6 0.2 0.1 10 0.0 56 5 Sp er mi cid es 9.1 6.9 2.2 0.0 0.0 0.0 0.0 89 .4 1.4 0.0 1.4 0.0 0.0 0.0 0.0 10 0.0 66 Tu ba l L iga tio n 97 .0 1.9 65 .9 21 .7 4.8 2.8 0.0 0.0 3.0 0.0 0.0 0.0 0.0 3.0 0.0 10 0.0 10 3 * E xc lud es 5 wo me n w ho w er e u sin g o the r m od er n m eth od s. Ch ar ac te ris tic To ta l No . o f Ca se s He alt h Se ct or Ot he r REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 160 Table 8.4.1 Desire to Use a Different Contraceptive Method and Preferred Method by Selected Characteristics Among Married Women Aged 15–44 Who Are Currently Using Modern Methods Reproductive Health Survey: Georgia, 2010 Percent All Users IUD TubalLigation Pill Condoms Sper- micides Calendar (Rhythm) Method Others/Does Not Know Total No. of Cases Total 15.8 1,413 68.3 12.5 10.4 2.5 2.2 2.3 1.8 100.0 230 Residence Tbilisi 19.6 379 68.6 11.6 9.3 2.3 1.2 4.7 2.3 100.0 77 Other Urban 13.6 373 72.1 5.7 12.1 4.1 2.1 1.7 2.1 100.0 56 Rural 14.4 661 65.6 17.6 10.4 1.7 3.4 0.3 1.0 100.0 97 Age Group 15–24 17.6 211 84.2 2.7 6.5 2.9 0.0 0.0 3.7 100.0 42 25–34 17.9 687 68.7 13.1 10.5 2.0 2.6 1.8 1.2 100.0 126 35–44 12.6 515 59.0 16.7 12.3 3.1 2.7 4.4 1.7 100.0 62 Number of Living Children 0–1 15.7 388 70.4 7.1 18.0 1.8 0.0 2.1 0.6 100.0 69 2 16.7 799 65.3 13.5 8.5 3.5 3.8 3.0 2.5 100.0 134 3 or more 13.3 226 76.1 18.3 4.5 0.0 0.0 0.0 1.1 100.0 27 Education Level Secondary incomplete or less 7.5 199 * * * * * * * 100.0 16 Secondary complete 13.0 324 70.5 13.5 2.8 8.0 5.3 0.0 0.0 100.0 43 Technicum 18.2 208 84.1 7.7 5.2 0.3 0.0 0.0 2.7 100.0 38 University/postgraduate 18.8 682 66.4 11.7 13.3 1.1 1.5 4.0 2.0 100.0 133 Wealth Quintile Lowest 17.3 168 87.8 7.4 3.3 0.0 0.0 0.0 1.5 100.0 27 Second 11.8 284 67.2 16.5 1.7 3.7 10.1 0.8 0.0 100.0 36 Middle 14.7 336 58.5 21.2 13.3 0.8 1.9 1.9 2.4 100.0 55 Fourth 17.6 227 70.8 5.2 10.3 5.2 2.7 5.0 0.9 100.0 37 Highest 17.4 398 67.1 11.3 14.0 2.6 0.0 2.5 2.6 100.0 75 Current Use of Contraception Pill 17.4 176 78.2 0.0 NA 11.0 7.3 3.1 0.4 100.0 29 IUD 2.6 498 NA * * * * * * 100.0 13 Condoms 30.6 565 71.5 11.4 11.5 NA 1.1 1.8 2.1 100.0 173 Spermicides 18.8 66 75.6 8.7 15.7 0.0 NA 0.0 0.0 100.0 13 Tubal Ligation 0.0 103 * * * * * * * 100.0 0 Other modern methods 21.6 5 * * * * * * * 100.0 2 Has Concerns About Current Method Yes 66.3 128 62.0 18.8 11.4 3.8 2.3 0.0 1.7 100.0 85 No 11.0 1,285 71.9 8.8 9.8 1.8 2.1 3.7 1.8 100.0 145 * Less than 25 cases. NA: not applicable; same method as currently used. Desires to Use a Different Method Preferred Method of Contraception Characteristic FINAL REPORT 161 Table 8.5.1 Selected Factors That Were Important or Somewhat Important in Deciding to Use a Traditional Method Instead of a Modern Method, by Selected Characteristics Among Married Women Aged 15–44 Who Currently Use Traditional Methods – Reproductive Health Survey: Georgia, 2010 Fear of or Experience With Side Effects Little Knowledge of Modern Methods Cost Husband/ Partner's Choice Doctor's Recommendation Religious Beliefs Difficult to Get a Modern Method Another Persons Advice Total 89.8 66.6 74.8 66.7 45.3 52.9 50.8 40.1 797 Residence Tbilisi 90.1 65.5 66.9 66.9 41.5 59.9 35.2 46.5 123 Other Urban 88.5 57.2 66.6 65.7 45.3 56.2 38.4 41.1 159 Rural 90.1 70.3 80.4 67.0 46.6 49.5 60.3 37.7 515 Age Group 15–24 86.0 70.8 68.2 70.4 50.1 58.8 48.3 43.0 88 25–34 89.3 65.9 76.8 65.5 45.6 50.1 51.5 40.2 358 35–44 91.1 66.2 74.7 66.9 44.0 54.1 50.7 39.3 351 Number of Living Children 0–1 84.1 61.6 66.7 64.6 42.3 47.5 44.3 39.1 166 2 91.0 68.5 76.8 63.3 44.1 52.7 52.5 40.7 472 3 or more 92.3 66.5 77.7 78.1 52.0 59.1 52.6 39.7 159 Education Level Secondary incomplete or less 88.8 69.2 80.4 72.5 50.0 51.1 59.3 44.0 169 Secondary 87.7 73.1 74.0 70.7 41.3 48.5 56.8 34.7 238 Technicum 89.6 59.3 75.5 52.9 35.1 42.8 48.0 41.0 128 University/ postgraduate 92.1 62.6 71.9 65.3 49.8 61.4 42.0 41.9 262 Wealth Quintile Lowest 88.1 69.9 86.6 63.4 47.8 47.6 59.4 33.1 179 Second 88.1 66.9 77.3 65.6 42.6 51.6 61.8 43.8 211 Middle 93.2 69.3 76.7 68.2 46.7 48.8 52.2 36.6 191 Fourth 89.0 61.5 71.2 67.9 45.5 57.9 45.6 40.0 105 Highest 90.3 63.5 59.5 68.7 44.7 61.4 29.0 47.1 111 Ethnicity Georgian 91.4 65.5 74.3 65.7 46.9 57.0 48.4 40.6 651 Azeri 66.3 66.3 70.2 58.9 32.3 43.8 62.5 41.9 46 Armenian 92.9 77.5 82.3 80.0 36.8 27.2 65.0 30.8 86 Other * * * * * * * * 14 * Less than 25 cases. No. of CasesCharacteristic Selected Factors REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 162 Table 8.5.2 Perceived Effectiveness of Traditional Methods Compared to Modern Methods by Selected Characteristics Among Married Women Aged 15–44 Who Currently Use Traditional Methods – Reproductive Health Survey: Georgia, 2010 Current Method More Effective About Equally Effective Current Method Less Effective Does Not Know/ Not Sure Total 28.9 46.1 16.2 8.8 100.0 797 Residence Tbilisi 32.4 43.7 16.9 7.0 100.0 123 Other Urban 31.6 51.2 9.9 7.3 100.0 159 Rural 26.8 45.0 18.3 10.0 100.0 515 Age Group 15–24 24.2 50.7 14.2 10.9 100.0 88 25–34 26.2 46.4 18.4 9.0 100.0 358 35–44 32.5 44.6 14.8 8.2 100.0 351 Number of Living Children 0–1 31.5 48.7 12.6 7.2 100.0 166 2 28.1 43.8 19.1 8.9 100.0 472 3 or more 28.2 49.5 12.0 10.2 100.0 159 Education Level Secondary incomplete or less 30.8 38.0 16.5 14.7 100.0 169 Secondary complete 30.1 42.2 17.8 9.9 100.0 238 Technicum 23.4 52.6 16.5 7.5 100.0 128 University/postgraduate 28.8 51.5 14.7 5.0 100.0 262 Wealth Quintile Lowest 26.9 43.9 18.7 10.5 100.0 179 Second 26.6 45.6 16.3 11.5 100.0 211 Middle 26.7 45.0 18.5 9.8 100.0 191 Fourth 37.9 47.6 12.0 2.5 100.0 105 Highest 29.4 49.0 14.2 7.4 100.0 111 Ethnicity Georgian 30.4 46.8 16.5 6.2 100.0 651 Azeri 18.2 32.8 20.8 28.1 100.0 46 Armenian 21.6 46.3 12.6 19.5 100.0 86 Other * * * * 100.0 14 * Less than 25 cases. Total No. of CasesCharacteristic Perceived Effectiveness FINAL REPORT 163 Table 8.6.1 Reasons for Not Currently Using Contraception by Selected Characteristics Among Married Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Reasons Related to Pregnancy, Fertility or Sexual Activity Other Does Not Know Total 76.8 22.3 0.9 100.0 1,888 Residence Urban 81.0 18.7 0.2 100.0 772 Rural 73.2 25.3 1.5 100.0 1,116 Region Kakheti 74.2 21.7 4.0 100.0 166 Tbilisi 81.2 18.5 0.3 100.0 313 Shida Kartli 80.8 19.2 0.0 100.0 103 Kvemo Kartli 74.0 23.8 2.2 100.0 189 Samtskhe–Javakheti 84.0 16.0 0.0 100.0 146 Adjara 72.3 27.7 0.0 100.0 159 Guria 70.9 28.4 0.7 100.0 128 Samegrelo 70.3 29.0 0.7 100.0 130 Imereti 78.7 20.7 0.6 100.0 279 Mtskheta–Mtianeti 76.6 23.4 0.0 100.0 143 Racha–Svaneti 78.7 21.3 0.0 100.0 132 Age Group 15–24 86.3 12.6 1.1 100.0 435 25–34 74.9 24.3 0.8 100.0 766 35–44 72.3 26.7 1.0 100.0 687 Number of Living Children 0–1 90.6 9.1 0.3 100.0 961 2 63.7 34.8 1.5 100.0 685 3 or more 59.9 38.5 1.6 100.0 242 Education Level Secondary incomplete or less 68.8 28.0 3.1 100.0 358 Secondary complete 75.6 24.0 0.4 100.0 557 Technicum 76.3 23.7 0.0 100.0 337 University/postgraduate 82.4 16.9 0.6 100.0 636 Wealth Quintile Lowest 67.2 29.5 3.3 100.0 380 Second 74.9 24.1 1.0 100.0 471 Middle 77.3 22.7 0.0 100.0 425 Fourth 82.4 17.3 0.3 100.0 291 Highest 81.8 17.9 0.3 100.0 321 Ethnicity Georgian 77.8 21.9 0.3 100.0 1,596 Azeri 64.9 30.0 5.1 100.0 121 Armenian 81.2 18.8 0.0 100.0 118 Other 70.8 21.5 7.7 100.0 53 Characteristic Type of Reason Total No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 164 Table 8.7.1 Desire to Use Contraception in the Future by Selected Characteristics Among Fecund Married Women Aged 15–44 Who Are Not Using Contraception Reproductive Health Survey: Georgia 2010 Desires to Use Within 12 Months Desires to Use Later Does Not Desire to Use Undecided Total 30.2 16.5 31.8 21.5 100.0 2,046 Residence Urban 29.8 18.4 29.5 22.2 100.0 910 Rural 30.5 14.7 34.1 20.7 100.0 1,136 Region Kakheti 31.9 14.0 28.5 25.6 100.0 174 Tbilisi 29.9 19.1 25.6 25.4 100.0 403 Shida Kartli 28.9 16.4 41.4 13.3 100.0 105 Kvemo Kartli 22.4 18.0 35.7 23.9 100.0 211 Samtskhe–Javakheti 21.7 18.5 27.0 32.8 100.0 155 Adjara 41.0 12.4 36.7 10.0 100.0 165 Guria 26.1 17.4 39.9 16.7 100.0 119 Samegrelo 26.5 17.2 31.1 25.2 100.0 131 Imereti 32.7 15.6 32.7 19.0 100.0 291 Mtskheta–Mtianeti 32.5 15.2 33.5 18.8 100.0 154 Racha–Svaneti 23.5 15.4 37.0 24.1 100.0 138 Age Group 15–24 42.3 29.7 9.1 18.9 100.0 468 25–34 36.7 18.7 19.2 25.3 100.0 829 35–44 15.7 5.7 59.3 19.3 100.0 749 Number of Living Children 0 20.8 29.1 22.8 27.4 100.0 409 1 31.7 19.4 24.5 24.3 100.0 693 2 32.5 11.2 39.5 16.7 100.0 697 3 or more 34.7 2.7 45.7 16.8 100.0 247 Education Level Secondary incomplete or less 25.9 12.3 35.5 26.4 100.0 390 Secondary complete 36.5 18.6 27.8 17.1 100.0 573 Technicum 22.9 18.0 39.7 19.4 100.0 349 University/postgraduate 30.8 16.4 29.6 23.2 100.0 734 Wealth Quintile Lowest 28.9 11.5 39.0 20.6 100.0 393 Second 29.6 15.7 31.9 22.9 100.0 485 Middle 31.4 16.0 32.8 19.7 100.0 430 Fourth 29.2 19.3 30.4 21.1 100.0 343 Highest 31.5 19.2 26.7 22.6 100.0 395 Ethnicity Georgian 30.7 16.3 32.6 20.4 100.0 1,726 Azeri 27.0 17.7 35.5 19.9 100.0 120 Armenian 26.6 19.0 20.9 33.6 100.0 131 Other 29.1 16.6 25.1 29.2 100.0 69 Characteristic Desire to Use Contraception in the Future Total No. of Cases FINAL REPORT 165 Table 8.7.2 Preferred Method of Contraception by Selected Characteristics Among Fecund Married Women Aged 15–44 Who Are Not Currently Using Contraception and Desire to Use Contraception in the Future Reproductive Health Survey: Georgia, 2010 IUD Condoms Pill Tubal Ligation Injectables Withdrawal Rhythm Does Not Know Total 46.7 14.3 13.5 2.5 0.1 6.5 6.2 8.4 100.0 940 Residence Tbilisi 36.8 26.8 15.5 0.8 0.0 2.9 6.7 9.2 100.0 191 Other Urban 46.6 14.9 13.5 2.7 0.0 3.4 7.7 9.2 100.0 243 Rural 51.8 7.6 12.5 3.2 0.2 10.0 5.3 7.5 100.0 506 Age Group 15–24 45.2 14.3 15.4 2.6 0.3 1.9 4.5 15.1 100.0 331 25–34 55.6 13.3 12.6 2.6 0.0 4.9 3.6 5.5 100.0 456 35–44 26.9 17.0 11.6 1.8 0.0 20.6 17.0 0.9 100.0 153 Number of Living Children 0 40.3 22.1 12.0 0.0 0.0 0.5 3.2 21.9 100.0 184 1 47.1 12.1 17.4 3.9 0.0 5.1 5.0 8.2 100.0 356 2 51.6 13.5 11.9 1.8 0.4 8.5 7.7 1.8 100.0 312 3 or more 43.2 8.9 7.2 4.2 0.0 18.0 12.7 0.7 100.0 88 Education Level Secondary incomplete or less 53.9 7.3 12.9 3.4 0.0 12.1 2.6 6.8 100.0 148 Secondary complete 46.3 11.3 13.3 1.9 0.3 7.4 5.4 11.3 100.0 300 Technicum 42.4 11.1 19.8 4.9 0.0 6.3 7.2 8.2 100.0 137 University/postgraduate 45.6 21.4 11.6 1.6 0.0 3.2 8.2 6.3 100.0 355 Wealth Quintile Lowest 50.4 6.7 11.7 5.4 0.0 13.1 2.4 7.5 100.0 155 Second 53.7 6.9 13.7 3.4 0.5 8.7 5.3 7.4 100.0 216 Middle 43.3 15.3 12.6 2.4 0.0 5.4 9.2 9.0 100.0 208 Fourth 48.1 11.6 14.1 0.7 0.0 5.1 7.5 9.4 100.0 165 Highest 40.3 26.4 14.7 1.3 0.0 2.7 5.9 8.3 100.0 196 Characteristic No. of Cases Preferred Method of Contraception Total REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 166 Ta bl e 8 .7. 3 Pr ef er re d So ur ce o f C on tra ce pt ive M et ho ds b y S ele ct ed C ha ra ct er ist ics A m on g Fe cu nd M ar rie d W om en A ge d 15 –4 4 W ho A re N ot C ur re nt ly Us in g Co nt ra ce pt io n an d De sir e t o Us e C on tra ce pt io n in th e F ut ur e Re pr od uc tiv e H ea lth S ur ve y: G eo rg ia, 20 10 Ph ar m ac y W om en 's Co ns ul ta tio n Cl in ic Ci ty H os pi ta l Re gi on al Ho sp ita l Pr im ar y He alt h Ca re Cl in ic/ C en te r Po lic lin ic Fa m ily Me di cin e Ce nt er Re fe rra l Ho sp ita l Mo bi le Cl in ic Pa rtn er / Hu sb an d Re lat ive Ot he r Do N ot K no w To ta l 32 .5 13 .0 8.9 3.8 2.1 0.8 0.3 0.1 36 .5 0.3 0.1 0.0 1.4 10 0.0 75 6 Re sid en ce Tb ilis i 32 .0 7. 7 0. 0 2. 6 2. 1 1. 0 0. 0 0. 0 53 .6 0. 5 0. 0 0. 0 0. 5 10 0. 0 15 6 O th er U rb an 37 .1 11 .5 6. 0 2. 8 1. 7 1. 0 1. 1 0. 0 37 .5 0. 0 0. 0 0. 0 1. 5 10 0. 0 19 4 Ru ra l 30 .3 16 .6 15 .3 5. 1 2. 4 0. 7 0. 1 0. 3 26 .8 0. 3 0. 3 0. 0 1. 9 10 0. 0 40 6 Ag e G ro up 15 –2 4 30 .0 13 .5 7. 6 4. 6 1. 7 0. 7 0. 7 0. 3 38 .7 0. 4 0. 4 0. 0 1. 4 10 0. 0 26 2 25 –3 4 36 .0 14 .3 10 .8 3. 0 2. 8 0. 6 0. 1 0. 0 30 .7 0. 0 0. 0 0. 0 1. 8 10 0. 0 39 3 35 –4 4 27 .3 6. 7 5. 8 4. 6 1. 0 1. 9 0. 0 0. 0 51 .7 1. 0 0. 0 0. 0 0. 0 10 0. 0 10 1 Nu m be r o f L ivi ng C hi ld re n 0 27 .7 13 .9 8. 3 1. 8 0. 9 0. 7 0. 0 0. 0 46 .1 0. 0 0. 0 0. 0 0. 7 10 0. 0 13 9 1 33 .2 13 .4 6. 1 5. 3 3. 1 0. 8 0. 4 0. 3 34 .4 0. 7 0. 4 0. 0 2. 1 10 0. 0 29 5 2 35 .1 14 .0 9. 9 4. 0 2. 0 0. 9 0. 1 0. 0 32 .5 0. 0 0. 0 0. 0 1. 4 10 0. 0 25 8 3 or m or e 31 .1 5. 3 19 .3 1. 3 0. 6 1. 3 1. 6 0. 0 39 .5 0. 0 0. 0 0. 0 0. 0 10 0. 0 64 Ed uc at io n Le ve l Se co nd ar y in co m pl et e or le ss 31 .2 11 .3 15 .8 5. 9 4. 6 0. 8 0. 0 0. 0 27 .7 0. 9 0. 0 0. 0 1. 8 10 0. 0 11 4 Se co nd ar y co m pl et e 28 .5 14 .0 13 .3 2. 8 1. 1 0. 0 0. 1 0. 0 37 .9 0. 0 0. 4 0. 0 1. 8 10 0. 0 23 6 Te ch ni cu m 29 .1 13 .1 9. 6 5. 9 0. 3 1. 8 1. 0 0. 9 37 .1 0. 0 0. 0 0. 0 1. 0 10 0. 0 10 9 Un ive rs ity /p os tg ra du at e 37 .8 12 .7 2. 0 3. 1 2. 6 1. 2 0. 4 0. 0 38 .7 0. 4 0. 0 0. 0 1. 1 10 0. 0 29 7 W ea lth Q ui nt ile Lo we st 22 .6 16 .1 23 .8 3. 8 1. 9 0. 3 0. 0 0. 9 28 .5 0. 0 0. 0 0. 0 2. 2 10 0. 0 12 4 Se co nd 29 .5 19 .0 12 .6 8. 9 3. 2 0. 7 0. 9 0. 0 22 .4 0. 0 0. 0 0. 1 2. 8 10 0. 0 17 5 M id dl e 35 .6 9. 2 11 .5 1. 9 1. 6 1. 3 0. 0 0. 0 36 .8 1. 4 0. 7 0. 0 0. 0 10 0. 0 16 1 Fo ur th 40 .6 11 .2 2. 3 3. 7 0. 7 0. 7 0. 0 0. 0 39 .5 0. 0 0. 0 0. 0 1. 3 10 0. 0 13 2 Hi gh es t 32 .1 10 .8 0. 6 1. 5 2. 8 1. 0 0. 5 0. 0 49 .6 0. 0 0. 0 0. 0 1. 1 10 0. 0 16 4 Pr ef er re d Me th od Pi ll 9. 8 3. 1 2. 5 3. 1 1. 2 1. 5 0. 0 0. 0 77 .9 0. 0 0. 0 0. 1 0. 7 10 0. 0 12 7 IU D 49 .7 18 .8 13 .7 5. 1 2. 9 0. 4 0. 3 0. 0 7. 2 0. 0 0. 2 0. 0 1. 7 10 0. 0 44 8 Co nd om s/ sp er m ici de s 3. 9 0. 0 0. 0 0. 0 0. 9 0. 7 0. 0 0. 0 91 .8 1. 3 0. 0 0. 0 1. 4 10 0. 0 15 0 O th er 20 .9 40 .9 11 .4 9. 0 0. 0 5. 8 4. 3 4. 0 3. 8 0. 0 0. 0 0. 0 0. 0 10 0. 0 31 Ch ar ac te ris tic To ta l No . o f Ca se s Ot he r He alt h Se ct or FINAL REPORT 167 Table 8.8.1 Contraceptive Failure and Discontinuation Rates After One, Two, and Three Years for Selected Methods of Contraception All Segments of Contraceptive Use Initiated Since January 2005 Reproductive Health Survey: Georgia, 2010 IUD Condom Pill Other Modern Methods Calendar (Rhythm) Method Withdrawal One Year 10.3 0.9 5.2 7.3 8.5 20.9 17.7 Two Years 17.2 1.7 10.0 10.0 13.1 33.2 30.2 Three Years 21.9 2.9 14.3 16.4 15.0 40.6 37.2 No. of Segments 3,981 545 1,183 542 255 663 793 IUD Condoms Pill Other Modern Methods Calendar (Rhythm) Method Withdrawal One Year 35.4 8.6 40.4 52.1 33.7 36.8 35.4 Two Years 53.4 18.7 59.3 69.3 48.8 61.1 53.8 Three Years 64.0 30.2 69.1 80.5 56.0 72.6 65.6 No. of Segments 3,981 545 1,183 542 255 663 793 % Discontinuation Due to Method Failure (12 months) 29.2 10.6 12.9 14.0 25.1 57.0 50.0 Duration Duration All Methods Method of Contraception Discontinuation Rates Method of Contraception Failure Rates All Methods REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 168 Table 8.8.2 Contraceptive Discontinuation Rates As of One Year by Primary Reason for Discontinuing Contraception. For Selected Methods of Contraception; All Segments of Contraceptive Use Initiated Since January 2005 Reproductive Health Survey: Georgia, 2010 IUD Condoms Pill Other Modern Methods Calendar (Rhythm) Method Withdrawal Total, for Net Rates† 35.4 8.6 40.4 52.1 33.7 36.8 35.4 Gross Rates* Got pregnant while using contraception 13.1 2.1 6.7 6.9 9.9 27.3 24.7 Partner's objections or absence 8.0 0.2 14.3 2.5 5.0 4.2 12.4 Negligence 4.3 0.0 4.7 2.9 1.8 11.2 2.4 Desired to become pregnant 9.6 6.4 12.4 9.9 8.7 7.1 9.7 Experienced or feared side effects 6.1 11.2 0.6 29.8 5.5 0.2 0.1 Switched to other method 4.1 0.2 4.9 1.6 4.8 7.5 4.2 Cost/Availability 3.2 0.0 6.3 6.1 6.8 0.2 0.1 Stopped to rest body/Physician Advice 3.5 7.9 2.2 9.6 2.3 1.2 0.2 Difficult or inconvenient to use 1.8 0.2 3.4 0.6 1.7 1.8 1.2 Other 2.1 1.7 2.8 0.8 3.0 2.3 1.6 No. of Cases 3,981 545 1,183 542 255 663 793 † Net discontinuation rates in this row. * Gross discontinuation rates in rest of table; they sum to more than the net rate in the "Total" row; see text footnote. Method of ContraceptionMain Reason for Discontinuing Contraception All Methods 169 CHAPTER 9 NEED FOR CONTRACEPTIVE SERVICES The concepts of potential demand and unmet need for contraception have been around since the 1960s, when researchers first demonstrated a gap in the de- veloping world between women’s fertility preferences and their use of contraception. The total potential demand for contraception is generally defined as the sum of current contraceptive use (met need) and the additional contraceptive use that would be required to eliminate unwanted or mistimed childbearing (un- met need). Thus, unmet need for contraception is a specific estimate that shows the gap between desired fertility and current contraceptive practices. Monitoring the “need” for contraception has been increasingly recognized as central to family planning efforts. By providing evidence about women whose contraceptive demand is not fully satisfied, data on unmet need can demonstrate the work left to be done in assisting women and couples to prevent un- intended pregnancies. In addition, such data can help assess whether national financial and political support is adequate for rectifying this problem. With the ad- dition in 2006 of a new target of universal access to reproductive health services to help assess progress in meeting the Millennium Development Goals (MDGs Target 5b), UN panels have also recommended “un- met need for contraception” as one of the indicators to be monitored globally. A second measure, unmet need for a modern contraceptive method, which ex- cludes less effective traditional methods such as pe- riodic abstinence and withdrawal, has been recom- mended as a supplement. These measures are based on data collected through large-scale, nationally rep- resentative surveys of women conducted periodically in both developing and developed worlds. Among those the Reproductive Health Surveys (RHS) in Georgia play an essential role in describing the cur- rent need and potential future demand for contracep- tive services, by assessing respondent fecundity and reproductive preferences. The surveys have employed the definition of unmet need (Bongaarts, 1991; West- off, 2006) that includes women currently married or in consensual unions who are currently sexually active (within the past month); who are currently exposed to the risk of pregnancy (excluding women not sexu- ally active, currently pregnant women, and women in postpartum abstinence or amenorrhea); who are fe- cund (neither they nor their partners have any subfe- cundity conditions); who do not want to become preg- nant (at the time of the interview); and who are not using any method of contraception. In addition, the formulation of unmet need was extended to cover all REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 170 women, to more accurately reflect the total number of women with an unfulfilled need for contraception. By documenting periodically the additional contracep- tive use that would be required to eliminate the risk of unintended pregnancies in Georgia, the surveys have helped with sharpen the family planning agenda and monitor and evaluate the effectiveness of ongoing programs, including the introduction of contraceptive logistics management, and the assessment of pro- gress toward universal access to reproductive health services. The time trends over the 1999 to 2010 pe- riod are a special strength. 9.1 Potential Demand and Unmet Need for Contraception Overall, the 2010 survey found that 39% of all women had a potential demand for contraception. Among married women, who are much more sexually active and at risk of unplanned pregnancies, the potential demand for contraception was much higher (65%), including 34% of current users of modern methods, 18% of current users of traditional methods, and 12% of nonusers (Table 9.1.1 and Figure 9.1.1). In Table 9.1.1 18.2% of married women are using traditional methods, and they are included along with the 12.3% of nonusers at risk, to total 30.5% having unmet need. About one in every three (35.3%) married women had no need for contraception because they were current- ly pregnant, trying to become pregnant, infecund, or had not had intercourse recently. In addition to the unmet need for any contraception (12.3%), the need for modern contraception (30.5%) is emphasized. It is always larger since it includes all traditional method users. It is particularly useful in countries where the use of traditional, high-failure methods is high. (It should be noted that these percentages are con- servative, since some pregnant women do not want either this pregnancy or any future ones, and action programs should provide postpartum contraception to address their needs as well.) * Abkhazia: Autonomous region not under goverment control Unmet Need for Any Contraception by Region Among Married Women Aged 15-44 Figure 9.1.2 Unmet Need for contraception (% Married Women) 15+ 10-14 <10* Potential Demand and Unmet Need for Any Contraception by Marital Status Among Women Aged 15-44 Figure 9.1.1 All Women Currently Married Previously Married Never Married No need for contraception60.8 35.3 88.5 99.7 20.6 34.2 5.8 10.8 18.2 7.7 12.3 5.4 Use of Modern Use of Traditional Method Unmet Need for Contraception 0% 20% 40% 60% 80% 100% FINAL REPORT 171 Some subgroups of married women exhibited much higher levels of unmet need than others (Table 9.1.2). Regional levels of unmet need for any contraception ranged from a high of 15%–16% in Adjara, Guria and Mtskheta-Mtianeti to 8%–9% in Tbilisi, Samstkhe-Ja- vakheti, and Shida Kartli (Figure 9.1.2). Unmet need for modern contraception is much great- er and ranged from a high of 38%-40% in Samstkhe-Ja- vakheti, Adjara, Guria, Racha-Svaneti and Kvemo Kartli to 23%–27% in Tbilisi, Samegrelo and Imereti (Figure 9.1.3). Generally, levels of unmet need, particularly lev- els of unmet need for modern contraception, were higher among rural women than urban women and increased with the number of living children (Figure 9.1.4). Respondents with secondary education or less had higher levels of unmet need than those with post- secondary education (Table 9.1.2). Georgia’s unmet need for modern contraception among married women was 30%, down from 44% in 1999 and 37% in 2005. That is nearly a one-third decline from 1999 (Figure 9.1.5). The unmet need for modern contraception among all women decreased from 27% to 18%, also a one-third decline. Practically all this decline resulted from increased use of modern methods among couples, while unmet need among never married and previously married women re- mained constant and very low. In absolute numbers, this decline represents an ap- parent decrease of approximately 75,000 women aged 15–44 with unmet need for modern contra- ception between 2005 and 2010 and could account for the observed substantial reduction in unplanned pregnancies and induced abortions. In Table 9.1.2, for modern methods, there is still a gap of 18% of all Georgian women aged 15–44 (31% * Abkhazia: Autonomous region not under goverment control Unmet Need for Modern Contraception by Region Among Married Women Aged 15-44 Figure 9.1.3 Unmet Need of Modern Contraception (% Married Women) <25 25-29 30-34 35+ * Current Unmet Need for Modern Contraception by Number of Living Children Among Married Women Aged 15-44 Figure 9.1.4 50 45 40 35 30 25 20 15 10 5 0 31 23 6 37 40 38 Total None One Two Three Four or More Percentage of Married Women with Unmet Need of Modern Contraception REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 172 of married women), however, with an unmet need. They have an unfulfilled desire to plan and space their childbearing and continue to be at risk of unplanned pregnancy. This translates into almost 180,000 cou- ples whose modern contraceptive needs are unmet. In order to reduce this gap, policymakers and pro- grams can target subgroups where unmet need is most concentrated, according to characteristics such as age, income, education, and ethnicity. 9.2 Potential Demand for Family Planning by Fertility Preferences Comparing the most recent data from population- based surveys in Eastern Europe and the Caucasus region countries, Armenia (52%, 2000) and Azerbai- jan (53%, 2001) had the highest unmet need for mod- ern contraception, followed by Ukraine (47%, 1999), Czech Republic (39%, 1993), Romania (39%, 1999) and Georgia (31%, 2010) (CDC and ORC Macro, 2003). Table 9.2.1 and Figure 9.2.1 give details; they also sep- arate unmet need by whether it relates to “spacing” or “limiting.” That is, in addition to measuring the overall demand for family planning services, the survey data also allow for estimates of both met and unmet need based on respondents’ fertility preferences (Table 9.2.2). Among respondents with potential demand for any contraceptive method or for a modern method, women who did not want to get pregnant right away but wanted to have children sometime in the future (including those who were undecided as to whether to have children or not) were classified as having un- met need for spacing births. Respondents who did not want (any) more children but were not doing anything to prevent pregnancy (or were using less effective tra- ditional methods) were considered to have an unmet need for limiting births. Similarly, respondents whose contraception needs were met (users of any methods or modern methods) were classified as having their needs met for both for spacing and limiting births. The final two columns of Table 9.2.1 show the percent of all unmet need due to limiting. For example, for Georgia in 2010, 68% of all unmet need for “any con- traception” is due to limiting (8.4/12.3) and 67% of unmet need for “modern contraception” is due to lim- iting (20.5/30.4). In nearly all countries limiting needs clearly dominate. Only in Turkmenistan and Uzbeki- stan is the limiting percentage as low as 50% or below. Generally, in Table 9.2.2 and Figure 9.2.2 unmet need for limiting births is higher than unmet need for spac- ing births, regardless of region or whether the stand- ard or expanded definition is used. Among women currently in union the unmet need for limiting births is two to three times higher than the unmet need for spacing births, a finding that is concordant with the low ideal family size and future reproductive inten- tions that are typical in this region. The unmet need for limiting births in Georgia declined between 1999 and 2010 by 14%, while the unmet need for spacing births remains the same (10%). The most common reasons for unmet need in Geor- gia are lack of information, fears about contraceptive side effects, and inconvenience of services. Women with unmet need typically have low awareness of ef- fective contraceptive methods, lack knowledge about how methods are used, and are less likely to believe that family planning services are readily accessible to them. In order to meet their needs, considerably more effort should be made to increase contraceptive awareness through Information Education and Communication (IEC) and Behavior Change Communication (BCC) pro- grams and to expand the availability of a wide array of effective, high quality, affordable contraceptive meth- ods, including long-term and permanent methods. In conclusion, policy makers and donors need to be Unmet Need for Modern Contraception by Marital Status Among Women Aged 15-44: 1999, 2005 and 2010 Figure 9.1.5 1999 2005 2010 Total Currently Married Previously Married Never Married 27% 22% 18% 44% 37% 31% 4% 7% 6% 0% 0% 0% FINAL REPORT 173 aware of the quantity of family planning commodities needed to satisfy the needs of all Georgian women who currently use modern methods (21% in Table 9.1.1 or around 207,000 users); in addition, they need to account for a potential increase in contraceptive commodities when users of traditional methods and those not currently using any method adopt modern methods. On the basis of just satisfying unmet alone, supply requirements may increase dramatically even if population growth is held constant. Further, changes in fertility preferences and in the timing of childbear- ing may also generate more users. Currently, all family planning activities are organized with donor support (chiefly from UNFPA and USAID) and are implemented by local governmental institu- tions and international or local NGOs. Donors support three key functions aimed at strengthening family planning services: 1) availability of a range of effec- tive and acceptable contraceptive methods in family planning outlets; 2) training for family planning health personnel through general training programs; and 3) information dissemination and community-based ed- ucation and outreach activities. Satisfying the unmet need for modern contraception in Georgia will require a substantial increase in pro- grammatic and financial support. Currently, the ma- jority of contraceptive services are paid for through donor contributions and consumer payments, while government family planning subsidies remain limited. To better meet the demand for family planning servic- es, the government needs to scale up its partnership with the donor community to make services afford- able and accessible to all couples in need of services. The national reproductive health strategy should pro- vide free or low-cost contraceptive supplies, educate women about what methods and services are avail- able, and disseminate accurate information to counter incorrect beliefs about modern contraceptives. The national strategy should give high priority to making contraception practice more acceptable, in line with the MDG goal of universal access to reproductive health services. CZ MD RO RU UA AM AZ Ge10 KZ KG TM UZ 60 50 40 30 20 10 0 Unmet Need for Any Contraception and Unmet Need for Modern Contraception Among Married Women in Selected Countries in Eastern Europe and Eurasia Figure 9.2.1 Eastern Europe Caucasus Central Asia Source: CDC and ORC/Macro, 2003. Reproductive, Maternal and Child Health in Eastern Europe and Eurasia: A Comparative Report. Note: CZ=Czech Re.; MD=Moldova; RO=Romania; RU=Russia; UA=Ukraine; AM=Armenia; AZ=Azerbaijan; GE=Georgia; KZ=Kazakhstan; KG=Kyrgyzstan; TM=Turkmenistan; UZ=Uzbekistan. 15 39 6 29 39 12 33 6 18 47 15 12 12 14 13 19 14 52 53 31 22 22 27 18 Unmet Need for Modern Methods Among Married Women by Future Fertility Preferences; Reproductive Health Surveys 1999, 2005 and 2010 Figure 9.2.2 Unmet Need for Limiting 1999 10 34 28 20 9 10 2005 2010 Unmet Need for Spacing REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 174 Table 9.1.1 Demand for Family Planning (FP) Services by Marital Status and Age Group Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Married Previously Married Never Married 15–24 25–34 35–44 No Demand 60.8 35.3 88.5 99.7 85.3 49.1 44.1 Never had sexual intercourse 34.2 0.0 0.0 99.7 67.7 19.0 10.2 Not currently sexually active* 8.7 5.6 82.2 0.0 2.7 9.0 15.6 Currently pregnant or post–partum 7.6 12.8 1.3 0.0 10.4 9.4 2.3 Seeking to get pregnant† 4.9 8.2 1.1 0.0 4.1 6.8 3.8 Infecund/subfecund‡ 5.4 8.7 3.9 0.0 0.4 4.9 12.2 Potential Demand 39.1 64.7 11.4 0.2 14.8 51.0 55.8 Met Need 31.4 52.4 6.0 0.0 11.5 42.7 43.5 Current users of a modern method 20.6 34.2 5.8 0.0 8.3 28.9 26.7 Current users of a traditional method 10.8 18.2 0.2 0.0 3.2 13.8 16.8 Unmet need for any contraception (Nonusers at risk of unintended pregnancy) 7.7 12.3 5.4 0.2 3.3 8.3 12.3 Unmet Need for Modern Contraception§ 18.5 30.5 5.6 0.2 6.5 22.1 29.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 6,292 4,098 389 1,805 1,960 2,359 1,973 * Within the past month. † Want to get pregnant right away; includes 115 respondents who answered "when God wants." ‡ Sterilization surgery for noncontraceptive reasons, medical conditions that preclude pregnancy, infertile partners, and menopause. § Includes nonusers at risk of unintended pregnancy and current users of traditional contraceptive methods. Demand for Family Planning Total Marital Status Age Group FINAL REPORT 175 Table 9.1.2 Unmet Need for Family Planning (FP) Services by Marital Status and Age Group Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Any Method Modern Method Any Method Modern Method Total 7.7 18.5 6,292 12.3 30.5 4,098 Residence Urban 6.1 14.2 2,975 10.1 24.8 1,806 Rural 9.5 23.2 3,317 14.5 36.0 2,292 Region Kakheti 9.5 18.2 498 14.2 27.9 348 Tbilisi 5.3 12.7 1,426 8.9 23.2 815 Shida Kartli 5.7 21.1 392 9.0 34.2 266 Kvemo Kartli 9.7 24.6 546 14.4 37.6 375 Samtskhe–Javakheti 5.0 24.7 481 7.6 39.8 331 Adjara 10.5 25.0 419 15.7 38.3 292 Guria 10.2 25.0 401 15.1 38.4 276 Samegrelo 7.4 15.1 477 13.1 26.7 302 Imereti 8.5 17.4 805 13.5 27.8 540 Mtskheta–Mtianeti 10.8 19.4 393 16.2 29.7 270 Racha–Svaneti 8.2 21.8 454 14.2 37.8 283 Age Group 15–19 1.0 1.4 861 9.0 13.1 124 20–24 5.5 11.3 1,099 10.7 22.6 610 25–29 7.7 18.8 1,191 10.7 26.4 863 30–34 9.0 25.5 1,168 10.7 31.9 948 35–39 11.1 29.6 1,051 13.1 36.3 836 40–44 13.7 28.5 922 16.8 36.2 717 No. of Living Children 0 0.9 1.0 2,276 4.6 5.8 409 1 8.2 19.9 1,286 8.9 23.0 1,106 2 14.0 34.9 2,069 14.6 36.9 1,956 3 or more 16.0 38.5 661 15.8 39.5 627 Education Level Secondary incomplete or less 8.4 18.7 1,330 17.6 39.9 726 Secondary complete 9.2 21.9 1,568 13.9 33.4 1,119 Technicum 11.2 22.4 903 14.7 30.5 673 University/postgraduate 5.2 14.9 2,491 7.8 24.2 1,580 Wealth Quintile Lowest 12.4 27.2 1,093 18.6 42.1 727 Second 9.0 22.9 1,385 13.9 35.7 966 Middle 6.4 17.4 1,413 10.4 28.1 952 Fourth 6.9 15.5 1,037 11.3 27.3 623 Highest 5.6 13.2 1,364 9.3 22.9 830 Ethnicity Georgian 7.0 17.2 5,488 11.4 28.8 3,521 Azeri 16.3 32.1 276 22.5 44.4 219 Armenian 7.5 24.9 364 11.8 41.3 249 Other 12.1 20.1 164 18.0 30.1 109 No. of CasesCharacteristic All Women No. of Cases Married Women REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 176 Table 9.2.2 Met and Unmet Need for Family Planning (FP) Services Among All Women and Among Women in Union Aged 15–44 According to Their Future Fertility Preferences Reproductive Health Survey: Georgia, 2010 Any Method % Any Modern Method % Any Method % Any Modern Method % Total Demand for FP 39.1 39.1 64.7 64.6 Demand for spacing 13.6 13.6 22.3 22.3 Demand for limiting 25.5 25.5 42.4 42.3 Met Need For FP (Users) 31.4 20.6 52.4 34.2 For spacing 11.1 7.5 18.4 12.4 For limiting 20.3 13.1 34.0 21.8 Unmet Need For FP (Non-Users) 7.7 18.5 12.3 30.4 For spacing 2.5 6.1 3.9 9.9 For limiting 5.2 12.4 8.4 20.5 % of Demand Satisfied 80.3 52.7 81.0 52.9 For spacing 81.6 55.1 82.5 55.6 For limiting 79.6 51.4 80.2 51.5 No. of Cases 6,292 6,292 4,098 4,098 Characteristic All Women Women In Union Table 9.2.1 Percentage of Currently Married Women of Reproductive Age* With Unmet Need for Contraception by Future Fertility Preferences Selected Countries in Eastern Europe and Eurasia Total For Spacing For Limiting Total For Spacing For Limiting Any Method Modern Method Eastern Europe Czech Rep., 1993 14.6 3.9 10.7 38.9 11.9 27.0 73 69 Moldova, 1997 5.9 2.5 3.4 28.9 9.3 19.6 58 68 Romania, 1999 5.6 1.7 3.9 39.2 9.4 29.8 70 76 Russia, 1999‡ 11.5 2.4 9.1 32.5 7.0 25.5 79 78 Ukraine, 1999 17.5 3.4 14.1 47.2 8.1 39.1 81 83 Caucasus Armenia, 2000 15.0 4.0 11.0 52.0 10.0 42.0 73 81 Azerbaijan, 2001 11.5 1.8 9.7 53.3 8.2 45.1 84 85 Georgia, 1999 23.8 5.7 18.1 44.1 9.9 34.2 76 78 Georgia, 2005 16.3 4.3 12.0 36.9 8.6 28.3 74 77 Georgia, 2010 12.3 3.9 8.4 30.4 9.9 20.5 68 67 Central Asia Kazakhstan, 1999 15.0 6.0 9.0 22.0 9.0 13.0 60 59 Kyrgyz Rep., 1997 13.0 5.0 8.0 22.0 9.0 13.0 62 59 Turkmenistan, 2000 19.0 11.0 8.0 27.0 14.0 13.0 42 48 Uzbekistan, 1996 14.0 7.0 7.0 18.0 8.0 10.0 50 56 * Considered to be 15–44 years in RHS and 15–49 years in DHS surveys. † Women using folk methods or lactation amenorrhea method were classified as having unmet need for contraception. ‡ Data for Russia pertain to three primarily urban areas (Ivanovo Oblast, Perm and Yekaterinburg cities). Source: Serbanescu et al. in Reproductive, Maternal and Child Health in Eastern Europe and Eurasia: A Comparative Report. CDC and ORC/Macro, 2003. Region and Country Unmet Need for Any Contraception† Unmet Need for Modern Contraception % of Unmet Need due to Limiting 177 CHAPTER 10 CONTRACEPTIVE COUNSELING The choice of a contraceptive method should take into account the patient’s personal history, her life stage as to whether a short term or long term method is appropriate, the contraindications of particular meth- ods, and her past experience if any with modern con- traception. Without proper information and reassur- ance on side effects, for example on anxieties about menstruation disorders patients may soon discontin- ue and risk unplanned pregnancies. Instructions need to be clear and given in the lan- guage that the patient can understand. So far there is only limited evidence about what works to help users choose a method that they understand and will con- tinue to use. For example despite their high effective- ness, hormonal contraceptives suffer from poor ad- herence to the required regimen and suffer low rates for long-term continuation. Nevertheless for most methods there is a definite increase in contraceptive uptake when women are provided with educational materials and counseling sessions, and they often then prefer the more reliable modern methods. Fur- thermore, training for high quality counseling is need- ed to avoid careless prescriptions that go contrary to client expectations, leading to high discontinuation rates and general dissatisfaction (Moreau et al., 2007). 10.1 Client-Provider Communications Regarding Family Planning Family planning counseling and services in Georgia are provided by obstetricians, gynecologists and “re- productologists” (a concept unique to Georgia that in- cludes other physicians who have received extra train- ing related to reproductive issues). The Georgian Law on Medical Activities (Government of Georgia, 2001) specifies that physicians already licensed in closely related specialties can be licensed as “reproductolo- gists” after a short post-graduate course; physicians specialized in other areas must complete the full post- graduate course and residency before being licensed to as a reproductologist. An important component of the newly implemented reproductive health strategy is to train health professionals to provide family plan- ning counseling at all levels of medical care, including primary care. Both UNFPA and USAID have support- ed physician post-graduate training in contraceptive technology. A waiver issued by the MoLHSA for the USAID-funded project Healthy Women in Georgia (HWG) allowed for the first time primary care doc- tors, pediatricians, and nurses to be trained in fam- ily planning counseling and services under the project (JSI, 2009). Through UNFPA and USAID support, the number of family planning (FP) providers in Georgia REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 178 has increased substantially, particularly in the last five years. A recent survey of a sample of reproductolo- gists and general physicians in four regions conducted with UNFPA support documented that the majority (77%) of respondents received family planning train- ing, mostly after 2005. About two-thirds of providers were classified as having correct knowledge about FP methods, though fewer correctly answered questions related to the side effects of the IUD and oral contra- ceptives (Tsertsvadze et al., 2010). As in previous surveys, the 2010 survey included a series of questions to assess typical interactions be- tween family planning providers and their clients. Specifically, the survey asked about the extent to which health professionals had provided basic fam- ily planning information and services to women who had used a modern contraceptive method or had an abortion or a birth during the five years prior to the interview. Women who had used at least one modern contracep- tive method in the previous five years were asked who had advised them to use their most recent method. If the advice came from a health care provider (e.g., a physician, nurse or midwife), they were also asked about the content of the family planning counseling. Most respondents were advised by a gynecologist to use their current or most recent modern method (55%) and an additional 1% were advised by a nurse, midwife or general practitioner (Table 10.1. and Fig- ure 10.1.1). Most women who did not receive medi- cal advice started using their last method at the part- ner’s suggestion (24%), at their own counsel (9%), at the suggestion of friend (6%), or at the suggestion of a relative (4%), bypassing any family planning coun- seling. Only 1% chose a method at the suggestion of a pharmacist. The source of advice varied widely by the last modern method used (Figure 10.1.2). Almost all IUD users and women sterilized had chosen their method based on the advice of a heath care provider (94% and 90%, re- spectively), while 78% of pill and 51% of other modern contraceptive users did so. Only 12% of condom users were advised by a physician, nurse, or midwife. Most women who had used condoms did so because their partners suggested it (57%) or because they decided to do so themselves (20%) or because of a friend’s ad- vice (7%). For “Other” users most non-medical advice came from friends and relatives (36%). During provider-client interactions, 64% of women received general information about other contracep- tive methods (Figure 10.1.3); 59% were counseled about the effectiveness of the chosen method com- pared with other methods; 82% were told of possi- ble side effects of the chosen method; and 77% were told what to do if they experienced side effects (Table 10.1). Overall, 52% of women received comprehen- sive counseling; this was only slightly higher in rural (53%) than in urban (51%) areas. The content of counseling is very important since in- teractions between family planning providers and their clients, and the messages conveyed during those interactions, can affect continued and correct use of the method as well as client satisfaction with the ser- vice. Regarding trends, between 1999 and 2010 there was very little change in the percentage of women who were advised by a health provider about their most recent method. However, the content of these inter- actions had improved significantly. By 2010 as noted above, during provider-client interactions, 64% of women received general information about other contraceptive methods, doubling from only 34% in 1999; 59% were counseled about the effectiveness of the chosen method in 2010 compared to only 31% in 1999, also a near doubling; and 82% reported that the provider had explained possible side effects of the method chosen, compared to 70% in 1999. Source of Contraceptive Advice for Most Recently Used Contraceptive Method Among All Women Aged 15-44 Who Had Used Modern Contraceptives in the Last 5 Years Figure 10.1.1 OB/Gyn 55 24 9 6 4 1 Partner Nobody Friend Relatives Pharmacist FINAL REPORT 179 The content of contraceptive counseling differed among the various methods. The content of contra- ceptive counseling varied also by the method chosen. For example IUD users were more likely to be coun- seled about side effects (91%) and what to do if they occur (86%) than were users of other contraceptive methods (Table 10.1). Sterilization users were the least likely to receive any counseling, particularly in- formation about other methods (49%) and contracep- tive effectiveness (48%). Women who used pills were the most likely to have received medical advice about other methods (73%) and contraceptive effectiveness (67%). Overall, condom and “Other” users were the least likely to receive comprehensive counseling (41% and 39%, respectively), whereas users of pills were the most likely (60%). Good communication between clients and family planning providers during counseling is a key to in- formed choice. When counseling is a partnership, in which clients and providers communicate openly, share information, express emotion, and ask and an- swer questions freely, clients are more satisfied, un- derstand and recall information better, use contracep- tion more effectively, and live healthier lives. The process of making informed family planning choices begins long before people visit a provider, and many people make informed choices without face-to- face communication with a provider. When clients do seek services, however, there is substantial evidence on what clients and providers can do together to en- sure that family planning decisions are based on the principle of informed choice. Client and health provider interactions offer important opportunities to promote counseling on risk behav- iors. Therefore integration of family planning coun- seling and services with primary health care (PHC) services is definitely recognized by MoLHSA and other concerned government agencies and partner organi- zations as a priority strategy. Integration is the com- bination of different kinds of services or operational programs to maximize reproductive health outcomes, including referrals from one service to another, as well as services provided in the same setting or by the same provider. Improved access to FP counseling and low cost or free contraceptives at the primary health care level and in hard to reach geographical locations (via mobile clinics) have been a priority among gov- ernment agencies and donors. To pursue this priority, Source of Contraceptive Advice By Type of Modern Method of Contraception Used Among All Women Aged 15–44 Who Had Used Modern Contraceptives in the Last 5 Years Figure 10.1.2 OB/Gyn Partner Nobody Friend/Relatives 78 94 12 90 51 57 2 000 1 1 5 5 20 15 5 7 2 36 Pill IUD Condom Female Sterilization Other Trends in Type of Counseling Received Among Women Aged 15-44 Who Had Used a Modern Method Withinthe Last 5 Years; 1999, 2005 and 2010 Figure 10.1.3 1999 2005 2010 General Information about other methods 34 Information about method’s effectiveness Information about possible side effects 62 64 31 59 59 70 80 82 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 180 more primary care doctors, pediatricians, and nurses need to be trained in techniques for family planning counseling and services. Beside training efforts, reg- ulations must be changed to allow PHC doctors and nurses to provide those services, probably with the exception of IUD insertion. 10.2 Satisfaction with Counseling Services Family planning clients and providers both have re- sponsibilities to ensure that the counseling process reflects the principle of informed choice and leads to family planning decisions that clients make for them- selves. A number of obstacles often stand in the way of good client-provider communication. These include unnecessary medical barriers and other restrictions that providers place on services, providers’ own pref- erences about contraception and biases toward or against certain methods, both providers’ and clients’ discomfort with discussing sexuality, the differences in status and knowledge between providers and clients, and gender bias. Finding ways to surmount these ob- stacles helps foster informed choice. Respondents who used a modern method in the last five years were asked about their satisfaction with the service provider (Table 10.2). Only 41% were “very satisfied” and 45%, “satisfied;” 11% were “somewhat satisfied,” while 3% were “dissatisfied.” Satisfaction varied little by respondent background characteris- tics. However satisfaction varied sharply by method: ratings were highest by IUD and sterilization users, but for all other methods the ratings were similar to each other, at much lower levels. Women who were counseled about all birth control methods at the time of making their contraceptive decision were more likely to be “very” satisfied with counseling than those who did not receive complete information (44% vs. 36%). Similarly, women who re- ceived counseling about method effectiveness were more likely to be very satisfied than those that did not (46% vs. 34%), as were women who received coun- seling about side effects (45% vs. 23%); similarly for counseling on what to do if side effects occur (43% vs. 32%); and for the receipt of comprehensive coun- seling (47% vs. 34%). Percentage of Women Aged 15-44 Who Were Very Satisfied or Satisfied with Specific Types of Counseling Received Among Women Who Had Used a Modern Method Within the Last 5 Years Figure 10.2.1 1999 2005 2010 General Information about other methods Information about method’s effectiveness Information about possible side effects 81 89 88 89 90 82 82 88 90 Satisfaction with Family Planning Services Among Women Aged 15–44 Who Have Received Contraceptive Counseling in the Last 5 Years Figure 10.2.2 Racha-Svaneti Mtskheta-Mtianeti Imereti Samegrelo Guria Adjara Samtskhe-Javakheti Kvemo Kartli Shida Kartli Kakheti Tbilisi 76 82 83 84 85 86 88 89 89 91 98 24 18 17 15 14 14 12 11 11 9 2 Very Satisfied/ Satisfied Somewhat Satisfied/ Not Satisfied FINAL REPORT 181 Compared to 1999, the percentage of women who were very satisfied or satisfied with specific counseling information changed as shown in the three categories in Figure 10.2.1. Satisfaction with specific types of counseling ranged from a high of 98% in the region of Samtskhe-Ja- vakheti to a low of 76% in the region of Kakheti (Figure 10.2.2). 10.3 Postabortion and Postpartum Counseling Meeting the contraceptive needs of clients at all stag- es of their reproductive lives is a vital aspect of quality reproductive health care. During the postpartum and postabortion phases, special considerations govern the provision of care. Postpartum contraception is the initiation and use of a contraceptive method in the first six weeks af- ter delivery to prevent unintended pregnancy, par- ticularly in the first 1-2 years after childbirth, when another pregnancy can be harmful to the mother or to a breastfeeding baby. Postabortion contraception is the initiation and use of a contraceptive method, most often immediately after treatment for abortion: within 48 hours, or before fecundity returns (2 weeks postabortion). The objective is to prevent unintended pregnancies, particularly for women who do not want to be pregnant and may undergo a subsequent unsafe abortion if contraception is not made available during this brief interval. The majority of women receiving postabortion care do not want to become pregnant again in the near future, and it is important that the contraceptive needs of women during this critical pe- riod are met. Unfortunately, a large number of women who wish to delay or prevent future pregnancies receive little or no information on safe, available, effective contraception for postpartum or postabortion use, including how and where to obtain a method, and how soon after childbirth and abortion use of a method should be initiated. Good counseling should address their fears as well, as women often have valid concerns that cer- tain methods may affect breastfeeding, reducing their breast milk or harming the growth and development of their infant. All respondents who had an abortion in the last five years were asked if they received any family planning advice either before or after the abortion procedure; if they received any contraceptive method or a pre- scription for any method; and if they were referred to a family planning facility following the procedure. Al- though 33% of respondents with a history of at least one abortion in the last five years reported receiv- ing contraceptive counseling around the time of the abortion, only 7% received a contraceptive method, prescription, or referral. Women in urban areas (36%) were more likely than rural residents (31%) to receive pre- or post- abortion information about contracep- tion. (Table 10.3.1; rows can sum to more than the to- tal figure due to use of multiple services). Receipt of contraception counseling or methods varied rather ir- regularly by abortion order (Figure 10.3.1; the “meth- ods” bars show the sum of “method distributed” and “prescription given” in Table 10.3.1). Compared to 1999, more women reported receipt of contraceptive information in 2010 (33%), and more women had received a contraceptive method or pre- scription as well (14%) (Figure 10.3.2). These levels of services are all quite low. They dem- onstrate that even if there is an increase in counseling, referrals, and provision of contraceptives there will re- main a great need to improve and expand services at the time of abortion and birth. Selected Family Planning Services Received at the Time of Legally Performed Abortions by Abortion Order Among Women Aged 15–44 Years Who Have Had at Least One Abortion in the Last 5 Years Figure 10.3.1 First Contraception Counseling Methods of Contarception 31 Second Third Fourth Fifth Sixth or Higher 14 34 17 31 11 15 36 19 42 11 33 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 182 Equally defective is the level of contraceptive coun- seling during perinatal health care visits (Table 10.3.2). Only 39% of women who gave birth in the last five years and had at least one prenatal care visit reported receiving family planning information as a component of the prenatal consultation. Similarly, only 43% of women who received postpartum care in the last five years reported contraceptive counseling on that occa- sion. These levels were not uniform across subgroups: counseling was directly correlated with residence, age, education and wealth quintile, so more coun- seling was received by urban, older, better educated, and wealthier women. Average levels of counseling are low but they im- proved considerably between 1999 and 2005, and again from 2005 to 2010. Compared to 1999, con- traceptive counseling during prenatal care increased from 20% to 39%, as did counseling during postnatal care visits, from 20% to 43% (Figure 10.3.3). One of the major advantages of postabortion and postpartum family planning services is that they do not require a separate clinical infrastructure or staff. The initiation of contraception during the immedi- ate postabortion and postpartum periods can lead to short-term and long-term cost savings for both the cli- ent and the provider. Once postabortion and postpar- tum family planning education and services become a routine part of the activities conducted at a maternity care center, they are easily institutionalized and sus- tained. Decisions about reproductive health and contracep- tive use are among the most crucial that people of childbearing age make. With widespread endorse- ment of informed choice for family planning, people can have better information, a wider range of op- tions, and more support to make appropriate deci- sions themselves. Ensuring informed choice in family planning should be the goal of donor agencies, gov- ernments, family planning programs, and providers everywhere. Receipt of Contraceptive Counseling at the Time of an Abortion on Request; 1999, 2005 and 2010 Figure 10.3.2 1999 Contraception Counseling Methods of Contarception 2005 2010 15 5 22 6 33 14 Receipt of Contraceptive Counseling at the Time of Prenatal or Postnatal Care; 1999, 2005 and 2010 Figure 10.3.3 1999 2005 2010 Counseling During Prenatal and Postnatal Care 20 26 39 20 31 43 Prenatal Care Postnatal Care FINAL REPORT 183 Table 10.1 Source of Contraceptive Advice and Type of Contraceptive Counseling, by Residence and By Type of Modern Method of Contraception Used Among All Women Aged 15–44 Who Have Used Modern Contraceptives in the Last 5 Years Reproductive Health Survey: Georgia, 2010 Urban Rural Pill IUD Condom FemaleSterilization Other Ob/Gyn 54.6 48.4 63.6 78.3 93.6 11.6 90.1 51.4 Partner/husband 24.2 28.0 18.6 0.0 0.0 56.6 1.7 0.4 Nobody 9.4 12.6 4.9 1.3 1.1 19.6 5.1 5.0 Friend 5.6 5.6 5.7 8.7 0.9 7.3 0.0 22.8 Relative 4.2 3.8 4.9 6.6 4.0 3.1 1.6 13.5 Pharmacist 1.1 1.2 0.8 2.7 0.0 1.1 0.0 5.3 Nurse/midwife 0.5 0.2 0.9 1.6 0.4 0.3 0.0 1.1 Other 0.4 0.3 0.6 0.8 0.0 0.4 1.5 0.4 Primary Person Who Advised User of Method Total Residence Modern Method of Contraception Other 0.4 0.3 0.6 0.8 0.0 0.4 1.5 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,871 1,010 861 271 612 792 107 89 Type of Counseling Total Urban Rural Pill IUD Condom FemaleSterilization Other General information about other methods 64.0 63.8 64.3 72.7 63.1 63.6 48.6 76.0 Information about method effectiveness 59.1 59.2 58.9 67.4 58.0 56.4 47.6 68.6 Information about possible side effects 81.9 81.7 82.2 78.2 91.1 53.2 70.7 67.9 What to do if side effects occur 77.3 75.9 78.8 78.9 85.9 47.5 60.9 61.1 Comprehensive 52.0 51.2 52.9 60.2 52.9 40.7 57.9 39.3 No. of Cases 1,015 480 535 212 572 88 95 48 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 184 Table 10.2 Satisfaction with Family Planning Services Among Women Aged 15–44 Who Have Received Contraceptive Counseling in the Last 5 Years Reproductive Health Survey: Georgia, 2010 Very Satisfied Satisfied Somewhat Satisfied Not Satisfied Total 40.7 45.3 10.7 3.3 100.0 1,015 Residence Urban 42.7 43.9 10.7 2.6 100.0 480 Rural 38.6 46.8 10.6 4.0 100.0 535 Age Group 15–24 34.2 47.6 13.0 5.3 100.0 135 25–34 40.9 45.3 10.2 3.5 100.0 499 35–44 42.8 44.5 10.4 2.3 100.0 381 Region Kakheti 29.4 47.1 19.3 4.2 100.0 110 Tbilisi 45.5 42.2 8.6 3.7 100.0 207 Shida Kartli 34.9 47.0 16.9 1.2 100.0 70 Kvemo Kartli 41.6 42.7 12.4 3.4 100.0 79 Samtskhe–Javakheti 28.3 69.6 0.0 2.2 100.0 37 Adjara 46.3 45.1 6.1 2.4 100.0 66 Guria 32.4 52.9 10.3 4.4 100.0 62 Samegrelo 47.5 35.6 14.4 2.5 100.0 104 Imereti 38.7 50.3 6.8 4.2 100.0 164 Mtskheta–Mtianeti 40.3 45.8 12.5 1.4 100.0 58 Racha–Svaneti 41.5 47.7 7.7 3.1 100.0 58 Education Level Secondary incomplete or less 36.9 44.0 16.1 3.0 100.0 180 Secondary complete 34.4 51.6 10.1 3.9 100.0 259 Technicum 48.3 41.7 6.2 3.8 100.0 152 University/postgraduate 43.3 43.5 10.4 2.9 100.0 424 Wealth Quintile Lowest 43.6 44.8 8.2 3.5 100.0 141 Second 39.5 46.8 10.1 3.5 100.0 226 Middle 35.8 45.5 14.2 4.5 100.0 250 Fourth 37.9 49.6 11.3 1.1 100.0 169 Highest 46.5 41.6 8.6 3.3 100.0 229 Method Used Pill 28.7 48.8 17.0 5.5 100.0 212 IUD 44.5 45.6 7.5 2.5 100.0 572 Condom 26.4 48.3 19.7 5.6 100.0 88 Other 28.5 44.8 19.9 6.8 100.0 48 Female sterilization 59.9 35.4 4.7 0.0 100.0 95 Counseled About All Methods No 35.8 46.6 12.9 4.7 100.0 371 Yes 43.5 44.6 9.4 2.5 100.0 644 Counseled About Method Effectiveness No 33.8 46.9 14.2 5.1 100.0 420 Yes 45.5 44.2 8.3 2.1 100.0 595 Counseled About Possible Side Effects No 22.5 46.0 23.6 7.9 100.0 187 Yes 44.7 45.2 7.8 2.3 100.0 828 Counseled for Knowledge About What to Do If Side Effects Occur No 31.8 44.9 18.1 5.2 100.0 238 Yes 43.3 45.4 8.5 2.8 100.0 777 Comprehensive Counseling No 34.4 46.5 14.2 5.0 100.0 499 Yes 46.5 44.2 7.5 1.8 100.0 516 No. of CasesCharacteristic Degree of Satisfaction Total FINAL REPORT 185 Table 10.3.1 Selected Family Planning Services Received at the Time of Legally Performed Abortions By Selected Characteristics Among Women Aged 15–44 Who Have Had at Least One Abortion in the Last 5 Years Reproductive Health Survey: Georgia, 2010 Total Before Abortion After Abortion Method Distributed Prescription Given Referral Given Total 33.1* 9.9 13.2 6.6 7.4 1.0 2,054 Residence Urban 35.6 10.5 13.6 6.1 9.2 1.2 768 Rural 31.3 9.4 12.8 6.9 6.1 0.9 1,286 Residence Tbilisi 36.3 9.7 11.8 4.1 9.7 1.8 333 Other Urban 35.0 11.2 15.3 8.0 8.6 0.7 435 Rural 31.3 9.4 12.8 6.9 6.1 0.9 1,286 Age Group 15–24 31.0 10.8 10.1 9.3 7.1 1.0 226 25–34 36.1 9.2 15.4 7.4 8.1 0.8 1,188 35–44 28.8 10.5 10.5 4.4 6.3 1.4 640 Education Level Secondary incomplete or less 30.6 6.5 14.7 6.1 6.5 1.9 456 Secondary complete 33.5 11.4 12.8 6.6 7.8 0.6 668 Technicum 27.1 7.7 8.1 3.7 7.5 0.4 286 University/ postgraduate 36.8 11.7 14.5 8.2 7.7 1.1 644 Socioeconomic Status Low 28.7 14.7 9.1 3.9 9.2 0.0 286 Middle 33.3 8.6 14.4 7.5 6.5 1.3 982 High 34.3 9.6 13.2 6.6 7.8 1.1 786 Ethnicity Georgian 34.9 10.5 13.4 7.6 6.9 0.7 1,661 Azeri 28.4 7.7 13.7 3.7 9.7 0.0 181 Armenian 26.3 9.0 13.7 1.9 8.9 6.1 141 Other 21.2 4.2 7.2 1.1 8.6 3.6 71 Order of Abortion First 30.5 10.5 12.1 7.4 7.0 0.6 576 Second 34.4 12.4 12.7 7.5 9.6 1.2 417 Third 30.6 9.0 11.9 5.6 5.2 0.4 291 Fourth 35.6 12.2 12.8 7.3 7.3 1.2 185 Fifth 41.8 10.4 17.4 10.8 8.1 1.3 135 Sixth or Higher 33.2 6.4 14.6 4.1 7.3 1.7 450 *Percent receiving any counseling or service. Rows can sum to more than the total figure due to use of multiple services Characteristic Contraception Counseling Distribution of Methods of Contraception, Prescriptions for Methods, or Referrals No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 186 Table 10.3.2 Family Planning Counseling Received During Prenatal and Postnatal Care By Selected Characteristics Among Women Aged 15–44 Who Received Perinatal Health Services in the Last 5 Years Reproductive Health Survey: Georgia, 2010 % No. of Cases % No. of Cases Total 39.2 2,575 43.0 611 Residence Urban 42.1 1,184 46.9 332 Rural 36.1 1,391 37.0 279 Residence Tbilisi 37.3 563 46.1 160 Other Urban 47.3 621 47.7 172 Rural 36.1 1,391 37.0 279 Age Group 15–24 36.2 722 36.0 147 25–34 39.0 1,473 43.1 375 35–44 45.7 380 55.5 89 Education Level Secondary incomplete or less 30.9 400 32.2 76 Secondary complete 36.2 724 33.7 134 Technicum 41.5 332 43.1 69 University/postgraduate 43.2 1,119 48.8 332 Wealth Quintile Lowest 28.1 410 36.2 69 Second 39.4 619 35.9 110 Middle 39.0 579 41.8 143 Fourth 41.9 406 41.4 118 Highest 43.0 561 49.9 171 Birth Order First 39.2 1,285 38.6 335 Second 38.5 924 46.0 206 Third or more 40.5 366 56.8 70 Characteristic Contraception Counseling During Prenatal Care Contraception Counseling During Postnatal Care 187 CHAPTER 11 OPINIONS ABOUT CONTRACEPTION Use of contraceptives remains relatively low in Geor- gia. Slightly more than half of married women (53%) use any method of contraceptive Since contraceptive practice is correlated with awareness and information about it, improved usage of methods and especially modern methods requires reliable data about what reproductive aged women think about specific details. According to GERHS10 survey results, practically all Georgian women have heard of at least one method of contraception. However, knowledge about the con- crete characteristics of the different contraceptives, such as advantages, disadvantages and use-effective- ness, is low. Unfortunately, some indicators related to attitudes and knowledge about contraception that had improved between the 1999 and 2005 surveys, do not show further gains in the 2010 survey. 11.1 Opinions on Method Effectiveness To assess awareness concerning the effectiveness of contraceptive methods all respondents were shown a list of 12 different methods and were asked to identify the most effective method for preventing pregnancy (Table 11.1 and Figure 11.1). International research shows female sterilization to have the highest use-ef- fectiveness, while withdrawal has the lowest; howev- er, only seven percent mentioned female sterilization. Three other methods were mentioned more frequent- ly by the respondents, including the condom, which is subject to substantial failures in ordinary practice. Pre- viously married women, older women, women with two or more children, and women with a high level of education, compared to other groups of respondents, were most likely to rank female sterilization first, but the percentages were small in all subgroups around the seven percent average. In Table 11.1, contracep- tive methods are listed from left to right according to their actual use-effectiveness in preventing pregnan- cy, but as the results show, respondents’ opinions do not correspond with this sequence. The IUD, which is considered second in terms of ac- tual use-effectiveness, was ranked first in effective- ness by 35% of the respondents, more than for any other method. However while condoms are ranked fourth in actual use-effectiveness, they were ranked first by 20% of respondents, second only to the IUD. Next, the pill came out third in terms of both actual effectiveness and respondent-rated effectiveness. It was followed by female sterilization, in fourth place as noted. With use-effectiveness that is in fact poor, the rhythm method was ranked fifth. As for the “other” category which included Norplant, emergency con- traception, injectable contraceptives, and vasectomy, REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 188 all very highly effective methods, only 1.3% of the respondents considered this category of methods as most effective. Sterilization and the IUD were ranked first more often by women who were older and had more children, quite systematically, at the expense of the condom. Otherwise the accuracy of the rankings of the various methods did not improve significantly as respondent’s education or wealth quintile increased. Unfortunately, the most effective methods are relatively less popular in Georgia, as confirmed by the 1999 and 2005 sur- veys as well as other Reproductive Health (RH) surveys carried out in Georgia (Khomasuridze, Kristesashvili, and Tsuladze, 2004; Kristesashvili and Tsuladze, 2002; and Kristesashvili et al. 2009). Overall, 16% of the women did not have an opinion on which method is most effective. That “no opinion” percentage varied greatly, and was very high among women aged 15-19 (42%), never married women (34%), and women with no children yet (32%). Most other groups had much lower percentages, showing that interest about contraception increases sharply as it becomes relevant to a woman’s circumstances. The percentage was also high for Azeri women (38%), and those with low educational attainment (29%). Figure Opinions Regarding Which is the Most Effective Contraceptive Method, by Residence, Among Women Aged 15-44 Figure 11.1 IUD OC Female Sterilization Condom 100 80 60 40 20 0 Trad. Methods 33 33 37 26 21 17 12 10 10 6 9 9 8 8 7 Tbilisi Other Urban Rural Contraceptive methods Figure 11.2.2 May Cause Weight Gain 100 80 60 40 20 0 1999 2005 2010 Disadvantages Opinions Regarding the Disadvantages Associated with Using OC Among Women Aged 15-44 Who Have Heard of Oral Contraceptives in 1999, 2005, and 2010 Difficult to Remember to Take Very Expensive Bad for Blood Circulation 31 52 54 40 42 46 14 16 24 10 15 14 Figure 11.2.1 Easy to get 100 80 60 40 20 0 1999 2005 2010 Advantages Opinions Regarding the Advantages of Using the Pill, Among Women Who Have Heard of it, for Women Aged 15-44, in 1999, 2005, 2010 Easy to use Regular Periods Reduced Bleeding 55 72 71 54 64 69 17 31 23 11 17 14 FINAL REPORT 189 Compared to the 2005 results, the percent of women who chose female sterilization as the most effective method hardly increased at all (from 6% to 7%), while the proportion of women who chose the IUD as the most effective actually declined (from 45% to 35%). Additionally, the percent of women having no opin- ion on the use-effectiveness of the methods increased (from 11% to 16%). In sum, lack of information, in addition to incorrect in- formation, about the various contraceptive methods appears to be widespread among women of repro- ductive age, indicating the need for improved infor- mation and education programs in the country. 11.2 Opinions on Advantages and Disadvantages of the Pill and the IUD To assess women’s information about the advantages and disadvantages of certain contraceptive methods, respondents who had heard of oral contraceptives and the IUD were asked to agree or disagree with several statements referring to their positive and negative ef- fects. Seventy-one percent of respondents agreed that the “Pill is easy to get, while 69% agreed that “It is easy to use.” They were less likely to agree that the pill makes menstrual periods more regular (23%) and reduces menstrual bleeding (14%) (Figure 11.2.1). The trend from 1999 to 2010 is sharply up for “easy to get” and “easy to use.” In general, the percentage of wom- en correctly identifying the advantages of the pill was higher as place of residence became more urban and as age, educational attainment, and wealth quartile increased (Table 11.2.1). About 54% of respondents agreed with the statement that the pill may cause weight gain, while 46% stated that remembering to take the pill every day is diffi- cult. A fourth (24%) agreed that the pill is very expen- sive, and 14% said that the use of the pill is “bad for blood circulation” (Figure 11.2.2.). Interestingly, the trend of opinion is up since 1999 for disadvantages as well as for advantages, suggesting that the pill is becoming better known by the public. However with about half of women who have heard of the pill saying it can cause weight gain and is difficult to remember to take, and a fourth seeing it as very expensive, it is not surprising that its use is low in the country. Accu- rate information concerning the pros and cons of the pill should come primarily from physicians; this once again reflects the need to improve their own knowl- edge and to enhance their role in counseling and as educators. For the IUD, three fifths (61%) of women who had heard of it said it is “Easy to use,” and half (51%) said it is “Relatively inexpensive.” As to disadvantages, a third (32%) said that it increases the risk of PID, and nearly a fourth (23%) said it could increase blood loss. The trend is up for “easy to use” and down for the two disadvantages of PID risk and blood loss, which points to an increasingly favorable image of the IUD and may encourage its adoption. All these percentages were higher among ever-married women and women aged 25-44, once again indicating that a woman’s life stage affects the relevance of contraception to her and her opinions about particular methods. Percentages were also higher with educational attainment and, gener- ally, with wealth quintile Slightly more than one-third (32%) of respondents agreed that IUD use increases the risk of pelvic inflammatory disease, while 23% agreed that the IUD increases blood loss during men- ses. (Table 11.2.2. and Figure 11.2.3). Overall women’s knowledge about the advantages, disadvantages, and use-effectiveness of contracep- tives is poor and presumably is not obtained from a reliable source such as a physician. However we can assume that the low level of counseling by physicians itself plays a serious role and again reflects the need to improve their educational role. Figure 11.2.3 Easy to use 100 80 60 40 20 0 1999 2005 2010 Disadvantages Opinions Regarding the Advantages and Disadvantages Associated with Using the IUD among Women Aged 15-44 Who Have Heard of the IUD in 1999, 2005, and 2010 Inexpensive Risk PID Blood Loss 44 56 61 43 54 51 39 38 32 27 25 23 Advantages REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 190 11.3 Opinions on the Risks of Contraceptive Use One of the determinants of modern contraceptive use is popular opinion regarding its risks to women’s health. All respondents were asked to evaluate the degree of risk to a woman’s health associated with the use of five modern contraceptive methods and abortion on request (Table 11.3.1, and Figures 11.3.1 to 11.3.5.) The series of tables from 11.3.2 through 11.3.6 gives details for each of the methods except the injectable, which is very little known in Georgia. In Table 11.3.1 the perceived risk was lowest for con- doms and highest for abortion. More than half of re- spondents believed that there is medium to high risk associated with oral contraceptive and IUD use; mere- ly 9% of respondents considered the risk to be low for oral contraceptives; 19% thought so for the IUD. High proportions of women “did not know” in Table 11.3.1 whether certain contraceptive methods posed a risk to a woman’s health. This was the lowest for condoms and abortion, at 19% each, and the highest for injectables (97%), which is related to the limited accessibility of injectables in the country. The per- centage not knowing was also very high also for fe- male sterilization (70%), which is little used. The low “don’t know” percentage for abortion is clearly relat- ed to its extensive use. In Tables 11.3.2 through 11.3.6 each method is con- sidered in turn, except the injectable, which is so lit- tle known. These tables all show perceptions of risk according to the various subgroups in the population. The oral contraceptive is considered first, and abor- tion last. The patterns across the subgroups vary ac- cording to the method, but the risk figures cannot be interpreted without attention to the “don’t know” percentages. The essential problem is that the “don’t know” per- centages remove many women from the other three columns in each table. In Table 11.3.2 for example, 41% of rural respondents said they didn’t know; con- sequently their other percentages for risk must be low. On the other hand, only 24% of Tbilisi respond- ents said they didn’t know, so their risk percentages are higher. That can be misleading, so the percep- tion of risk must be judged carefully. Of the rural women, about 60% had an opinion and of these, 32% are in the medium risk column, for a ratio of about half (32%/60%). But among Tbilisi women the same calculation uses 47%/76%, giving 62% who perceive medium risk. Thus among women with an opinion, far more Tbilisi women see the pill as risky than rural women do. The same problem affects the interpreta- tions for the other groups. The never-married group shows low percentages for risk, but most are in the don’t know column. Figure 11.3.1 Secondary Incomplete 100 80 60 40 20 0 Perceived Risk Levels for Abortion, by Education, with “Don’t knows” Removed. The Former Gradient Nearly Disappears, and the Perceived Risk Levels are Higher Secondary Complete Technicum University Low Risk Medium Risk High Risk Percent 1 21 78 1 20 79 18 80 0 1 14 85 Figure 11.3.2 Low Risk 100 80 60 40 20 0 Opinions Regarding the Level of Health Risk Associated with Using Selected Contraceptive Methods Among Women Aged 15-44 Medium Risk High Risk Don’t know Percent 9 12 19 68 6 38 41 14 19 13 1 10 34 27 19 72 Level of Health Risk Pill IUD Condoms Female Sterilization FINAL REPORT 191 The picture according to education is entirely reversed with this kind of correction. For abortion Table 11.3.6 shows a sharp gradient, with high risk rising with high- er education, from 53% to 76%, but the “don’t know” percentage drops from 33% to 11%. With a correction to remove the “don’t know” group, as Figure 11.3.1 shows, instead of the percentage for high risk rising it is nearly level at 79% to 85% in all groups. There are actually two groups in each of the Tables 11.3.2 to 11.3.6: one that has very little information about a method, which is of interest by itself, and the group that perceives some level of risk for the meth- od. For education, the first key message is that having an opinion increases steadily with education, but sec- ond, for those with an opinion, all education groups may turn out to agree on the degree of risk. The following Figures 11.3.2 to 11.3.5 retain all infor- mation in the tables, including the “don’t know” per- centages, since they gauge the lack of public informa- tion and the need for program actions to improve it. As Table 11.3.1 demonstrated, a full one-fifth (19%) of all women interviewed say they do not know the risk levels of abortion or condoms. However, to assess the perceived risks among those with an opinion, all figures must be adjusted to re- move the “don’t know” group, as illustrated above. Otherwise there is a distortion of the picture of per- ceived risk among those who have thought about it. 11.4 Desire for More Information on Contraceptive Methods The 2010 survey data confirm that women want to know more about contraception. Over half (53%) of respondents want more information. The percent- age rises among young adult women, never-married women, those with no living children, groups that cur- rently have least information. The percentage also rose with higher wealth quintiles. Women who had never used oral contraceptives were more interested in receiving additional information on contraception than ever-users were. Interestingly, as age and the number of living children increased the desire for more information decreased, perhaps because those groups already possessed more information than oth- ers (Table 11.4.1 and Figure 11.4.1). Respondents were asked what they considered to be the “best” source of information on contraception. The sources mentioned can be grouped into two dif- ferent categories: medical sources (e.g., gynecolo- gists), and nonmedical sources (e.g., radio/TV, friends/ peers, and mother). Ever married women, older wom- Figure 11.3.3 Low Risk 100 80 60 40 20 0 Opinions Regarding the Level of Health Risk Associated with Using Abortion on Request by Education Among Women Aged 15-44 Medium Risk High Risk Don’t know Percent 1 Level of Health Risk 1 10.4 14 15 15 12 53 61 33 24 15 11 Secondary incomplete or less Secondary complete Technicum University/postgraduate 70 76 Figure 11.3.4 1999 100 80 60 40 20 0 Opinions Regarding the Level of Health Risk Associated with Using Selected Contraceptive Methods Among Women Aged 15-44 Years in 1999, 2005 and 2010 Pill 2005 2010 1999 2005 2010 1999 2005 2010 IUD Condoms Don’t know High risk Medium riks Low risk REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 192 en, women with more education, and urban residents most frequently named gynecologists as the best source of information. Overall, among women who expressed an interest in receiving more information, 52% considered a gynecologist to be the best source of information; the other 48% preferred nonmedical sources of information. About 20% of women in this group identified TV/radio as the best source, followed by 10% who thought that newspapers and magazines to be the best source (Table 11.4.2 and Figure 11.4.2). These two sources (TV/radio and newspapers) make up a single category of information, “mass media,” so nearly one- third of respondents chose “mass media” as the best source of information on contraception. An additional nine percent mentioned books, three percent friends, and another three percent the In- ternet. Not surprisingly, the role of the internet has increased for obtaining information on contraception. About 4-6 % of young women, women with more education, those at the highest wealth quintile, and women residing in Tbilisi believed the Internet to be the best source of information. Interestingly, only two percent of all respondents mentioned their mothers as the best source. The per- cent was a little higher, up to six percent, among the never married, the young, and the less educated. In the 2010 survey, for half (52%) of reproductive age women the best source of information is the gynecol- ogist. Compared to adolescent girls, reproductive age women have more trust in the mass media. Thus, it is clear that gynecologists should pay more attention to their educational role in communicating with their pa- tients, and representatives of the mass media should take into consideration that 30% of women rely on them as their best source of information and that they have a societal duty. The 2010 survey results show the desire for more in- formation to be the same (53 %) as in 1999 and slightly lower (55%) than in 2005 (Figure 11.4.1). In the 2005 and 2010 surveys, a greater percentage of women under the age of 35 indicated a desire for more in- formation on contraceptives, compared to those aged 30 and older in both surveys. However, in 2010, fewer women aged 15-34 were interested in receiving infor- mation about contraceptives than women of the same age group in 2005, whereas the interest among older women aged 35-44 had increased by 10 percentage points. The sensitivity of the public to contraceptive infor- mation in the mass media is assessed in Table 11.4.3. The results are somewhat mixed: a full two-thirds of women favored this, but one fourth did not. The more conservative position appeared among the rural and less educated groups, as well as the lower wealth quintiles. It was unusual among the Azeri, 29% of whom did not know with the rest split evenly between “yes” and “no” replies. In general, contrary to the opinion of many among the more disadvantaged groups in the society, survey data clearly show the need for the majority of women of reproductive age to obtain more information on con- traception, including some from the mass media. At the same time it is also clear that obstetrician-gynecol- ogists should be considered as the primary source of correct information. The data obtained in these sur- veys should be taken into account in planning public information in future RH programs. Figure 11.3.5 Low Risk 100 80 60 40 20 0 Opinions Regarding the Level of Risk Associated with Using Abortion on Request Among Women Aged 15-44 Years in 1999, 2005 and 2010 Medium Risk High Risk Don’t know Percent Level of Risk 50 57 1999 2005 2010 66 25 33 14 8 1 1 19 19 9 FINAL REPORT 193 Table 11.1 Opinions Regarding Which Contraceptive Method Is the Most Effective by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Female Sterilization IUD (Spirali) Pill Condom Spermicides Other Modern* Rhythm Withdrawal None of Them Does Not Know Total 7.3 34.9 10.6 20.4 1.3 0.2 4.8 3.4 1.0 16.3 100.0 6,292 Residence Tbilisi 7.6 33.4 11.5 26.0 1.9 0.2 5.1 1.0 1.0 12.2 100.0 1,426 Other Urban 7.6 33.2 10.2 21.2 1.5 0.2 6.0 3.1 0.6 16.4 100.0 1,549 Rural 7.0 36.6 10.3 16.6 0.8 0.1 4.0 5.0 1.2 18.6 100.0 3,317 Marital Status Married 8.9 41.7 11.3 16.5 1.8 0.1 6.7 5.5 1.1 6.3 100.0 4,098 Previously married 9.1 38.5 8.0 22.0 1.4 0.6 6.4 1.1 1.6 11.3 100.0 389 Never married 4.3 22.3 9.9 26.7 0.3 0.1 1.3 0.1 0.7 34.4 100.0 1,805 Age Group 15–19 1.7 17.4 8.5 29.3 0.0 0.0 0.3 0.1 0.7 42.0 100.0 861 20–24 4.3 32.6 13.5 22.1 0.8 0.2 3.2 1.8 0.6 20.8 100.0 1,099 25–34 8.1 40.5 11.9 18.6 2.0 0.1 4.6 4.6 0.8 8.7 100.0 2,359 35–44 11.7 40.5 8.5 15.9 1.5 0.3 8.7 5.1 1.5 6.4 100.0 1,973 Number of Living Children 0 4.8 24.4 10.1 26.0 0.4 0.2 1.4 0.2 0.7 31.9 100.0 2,276 1 7.4 40.1 12.6 20.6 1.5 0.2 6.2 4.0 0.7 6.6 100.0 1,286 2 9.2 43.2 10.9 15.1 2.3 0.1 7.8 5.5 1.3 4.5 100.0 2,069 3 or more 12.0 43.2 7.7 12.2 1.6 0.1 7.3 9.1 1.7 5.2 100.0 661 Education Level Secondary incomplete or less 3.0 29.5 8.5 21.1 0.6 0.0 2.7 4.6 1.3 28.6 100.0 1,330 No. of CasesCharacteristic Method of Contraception Total p , Secondary complete 6.3 35.7 10.4 17.7 0.8 0.0 4.1 4.4 1.0 19.5 100.0 1,568 Technicum 11.1 40.8 10.5 14.7 1.9 0.1 7.2 3.2 0.5 10.1 100.0 903 University/ postgraduate 9.2 35.4 11.9 23.5 1.8 0.4 5.7 2.1 0.9 9.3 100.0 2,491 Wealth Quintile Lowest 6.6 35.5 10.0 16.6 0.4 0.1 3.7 6.4 1.4 19.3 100.0 1,093 Second 7.0 37.4 9.8 15.8 0.5 0.0 4.7 4.7 1.0 19.1 100.0 1,385 Middle 7.2 32.8 10.6 20.0 1.6 0.1 4.9 3.5 0.9 18.3 100.0 1,413 Fourth 6.8 35.4 10.3 21.4 1.3 0.1 6.0 2.7 1.4 14.6 100.0 1,037 Highest 8.5 33.9 11.6 25.4 2.1 0.3 4.6 1.1 0.5 12.0 100.0 1,364 Ethnicity Georgian 8.0 34.9 11.1 21.5 1.4 0.2 5.1 2.7 0.9 14.4 100.0 5,488 Azeri 1.8 34.2 5.8 5.3 0.3 0.0 3.0 10.7 1.2 37.7 100.0 276 Armenian 3.1 35.4 5.1 15.2 0.3 0.0 2.3 8.3 1.3 29.0 100.0 364 Other 5.9 34.3 14.8 23.0 2.3 0.0 2.7 2.9 2.5 11.6 100.0 164 * Other modern methods include: Norplant, emergency contraception, injectables, and vasectomy. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 194 Table 11.2.1 Opinions Regarding the Advantages and Disadvantages of Using Oral Contraceptives by Selected Characteristics Among All Women Aged 15–44 Who Have Ever Heard of Oral Contraceptives Reproductive Health Survey: Georgia, 2010 Easy to Get Easy to Use Regular Periods Reduced Bleeding May Cause Weight Gain Difficult to Remember to Take Very Expensive Bad for Blood Circulation Total 71.1 69.1 23.2 14.4 53.8 46.0 24.0 13.5 5,237 Residence Tbilisi 76.3 73.5 26.6 17.8 57.9 46.7 24.1 14.7 1,304 Other Urban 71.5 70.0 22.3 11.8 53.3 45.5 23.4 11.9 1,352 Rural 67.3 65.5 21.4 13.6 51.3 45.8 24.4 13.7 2,581 Marital Status Married 74.6 73.3 26.8 17.2 58.0 49.8 27.6 15.7 3,686 Previously married 74.3 71.1 29.7 16.5 57.2 48.9 26.3 15.4 347 Never married 62.0 58.6 13.0 7.3 43.0 36.1 15.0 7.9 1,204 Age Group 15–19 56.7 55.6 7.6 4.8 33.7 29.6 10.1 5.5 449 20–24 68.1 63.7 18.8 12.2 46.6 37.1 18.8 9.8 884 25–34 75.0 72.4 27.3 16.2 56.7 49.4 27.1 15.4 2,125 35–44 73.5 73.1 26.5 17.0 61.6 52.8 28.3 16.3 1,779 Education Level Secondary incomplete or less 58.2 60.9 14.6 7.4 40.3 37.4 19.4 7.2 833 Secondary complete 67.6 65.8 21.1 13.9 49.7 44.4 28.4 10.9 1,257 Technicum 74.4 71.2 26.0 15.2 59.7 49.7 25.5 19.4 827 University/postgraduate 76.7 73.1 26.6 17.0 59.1 48.8 23.0 15.3 2,320 Wealth Quintile Lowest 63.7 63.2 20.2 11.9 49.6 44.5 28.4 11.0 824 Second 66.4 64.6 20.6 12.5 49.7 45.7 24.6 14.8 1,077 Middle 69.5 68.7 22.1 12.4 54.3 46.6 23.3 13.0 1,160 Fourth 71.7 69.6 22.4 15.4 52.8 46.8 23.1 10.0 925 Highest 78.2 74.5 27.5 17.5 58.6 45.8 22.9 16.6 1,251 Ethnicity Georgian 72.7 70.2 23.8 14.9 56.2 47.3 24.4 14.3 4,709 Azeri 54.2 53.2 16.4 10.8 27.8 37.3 15.2 6.0 160 Armenian 51.5 53.6 12.6 8.8 29.9 31.5 25.5 7.0 237 Other 71.0 75.7 28.2 12.1 43.8 33.6 20.2 7.4 131 Characteristic No. of Cases Advantages Disadvantages FINAL REPORT 195 Table 11.2.2 Options Regarding the Advantages and Disadvantages of Using the IUD by Selected Characteristics Among All Women Aged 15–44 Who Have Ever Heard of the IUD Reproductive Health Survey: Georgia, 2010 Easy to Use RelativelyInexpensive Increases the Risk of Pelvic Inflammatory Disease May Increase Blood Loss Total 60.6 50.8 32.2 23.0 5,652 Residence Tbilisi 64.4 51.4 35.5 25.3 1,328 Other Urban 62.4 52.8 29.6 20.6 1,415 Rural 57.1 49.2 31.7 22.9 2,909 Marital Status Married 68.6 59.3 36.5 27.0 3,938 Previously married 63.1 52.3 41.9 29.0 369 Never married 41.6 30.8 20.1 12.2 1,345 Age Group 15–19 38.2 26.4 13.0 9.2 513 20–24 54.0 41.1 23.8 16.4 986 25–34 65.7 56.4 32.8 23.7 2,251 35–44 66.9 59.1 43.4 31.1 1,902 Education Level Secondary incomplete or less 52.6 41.6 20.7 15.2 982 Secondary complete 56.9 48.5 30.0 20.1 1,401 Technicum 64.1 59.1 38.6 29.1 884 University/postgraduate 64.8 53.1 36.2 25.8 2,385 Wealth Quintile Lowest 55.5 48.7 26.8 19.6 935 Second 56.3 46.4 30.9 20.9 1,221 Middle 59.5 52.5 33.7 22.5 1,261 Fourth 62.5 50.2 29.7 23.2 952 Highest 65.6 53.9 36.6 26.5 1,283 Ethnicity Georgian 61.3 51.7 33.4 24.1 5,005 Azeri 50.0 45.7 17.4 15.2 191 Armenian 53.3 41.1 22.7 10.3 308 Other 63.7 46.0 32.0 21.1 148 Characteristic No. of Cases Advantages Disadvantages REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 196 Table 11.3.1 Low Risk Medium Risk High Risk Does Not Know Pill 9.3 38.3 18.6 33.7 100.0 6,292 IUD 19.0 40.8 13.2 27.0 100.0 6,292 Condom 68.1 11.9 0.7 19.3 100.0 6,292 Female Sterilization 6.1 13.7 10.0 70.2 100.0 6,292 Injectables 0.4 1.8 1.1 96.8 100.0 6,292 Abortion on Request 1.0 13.5 66.2 19.4 100.0 6,292 No. of CasesTotal Degree of Risk Characteristic Opinions Regarding the Level of Health Risk From Using Selected Family Planning Methods Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Table 11.3.2 Low Risk Medium Risk High Risk Does Not Know Total 9.3 38.3 18.6 33.7 100.0 6,292 Residence Tbilisi 8.5 47.4 20.5 23.6 100.0 1,426 Other Urban 10.4 39.8 18.0 31.8 100.0 1,549 Rural 9.3 32.2 17.9 40.6 100.0 3,317 Marital Status Married 10.7 44.4 22.6 22.3 100.0 4,098 Previously married 9.6 43.3 23.3 23.8 100.0 389 Never married 7.0 27.0 10.8 55.2 100.0 1,805 Age Group 15–19 5.8 17.9 6.3 69.9 100.0 861 20–24 10.1 36.6 14.4 38.9 100.0 1,099 25–34 11.1 43.5 22.6 22.8 100.0 2,359 35–44 9.1 45.9 24.2 20.8 100.0 1,973 Education Level Secondary incomplete or less 6.1 24.4 10.2 59.3 100.0 1,330 Secondary complete 9.9 32.9 16.6 40.6 100.0 1,568 Technicum 9.9 45.9 23.9 20.3 100.0 903 University/postgraduate 10.7 47.2 23.0 19.2 100.0 2,491 Wealth Quintile Lowest 10.5 28.8 15.5 45.1 100.0 1,093 Second 9.4 31.6 17.7 41.3 100.0 1,385 Middle 8.1 35.4 19.6 36.9 100.0 1,413 Fourth 9.9 44.3 18.6 27.3 100.0 1,037 Highest 9.3 46.9 20.3 23.4 100.0 1,364 Ethnicity Georgian 10.0 40.6 19.4 30.0 100.0 5,488 Azeri 5.0 19.8 7.1 68.1 100.0 276 Armenian 2.4 23.9 16.7 57.1 100.0 364 Other 10.1 28.0 19.3 42.5 100.0 164 Ever Used Oral Contraceptives Yes 25.8 44.1 26.8 3.3 100.0 716 No 7.5 37.7 17.7 37.2 100.0 5,576 Characteristic Level of Health Risk Total No. of Cases Contraceptives by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Opinions Regarding the Level of Health Risk From Using Oral FINAL REPORT 197 Table 11.3.3 Opinions Regarding the Level of Health Risk From Using the IUD by Selected Characteristics, Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Low Risk Medium Risk High Risk Does Not Know Total 19.0 40.8 13.2 27.0 100.0 6,292 Residence Tbilisi 20.7 44.8 14.0 20.5 100.0 1,426 Other Urban 18.1 43.5 12.5 25.9 100.0 1,549 Rural 18.6 36.9 13.0 31.4 100.0 3,317 Marital Status Married 23.3 47.0 15.2 14.4 100.0 4,098 Previously married 19.5 46.7 17.0 16.9 100.0 389 Never married 11.6 28.9 8.9 50.6 100.0 1,805 Age Group 15–19 10.5 18.7 5.7 65.0 100.0 861 20–24 18.8 37.9 10.2 33.1 100.0 1,099 25–34 22.9 46.5 15.1 15.5 100.0 2,359 35–44 20.0 49.4 17.4 13.2 100.0 1,973 Education Level Secondary incomplete or less 15.2 27.2 8.4 49.2 100.0 1,330 Secondary complete 18.9 36.8 12.3 32.1 100.0 1,568 Technicum 21.1 50.2 15.5 13.2 100.0 903 University/postgraduate 20.7 47.9 15.7 15.8 100.0 2,491 Wealth Quintile Lowest 19.3 33.8 10.8 36.1 100.0 1,093 Second 19.3 36.3 13.1 31.3 100.0 1,385 Middle 16.7 41.2 14.2 27.9 100.0 1,413 Fourth 19.4 42.8 14.5 23.3 100.0 1,037 Highest 20.3 46.2 12.7 20.7 100.0 1,364 Ethnicity Georgian 19.6 42.3 13.7 24.4 100.0 5,488 Azeri 19.2 19.5 3.6 57.7 100.0 276 Armenian 10.0 34.6 14.8 40.6 100.0 364 Other 18.2 43.3 10.4 28.1 100.0 164 Ever Used IUD Yes 45.1 41.7 11.5 1.7 100.0 1,048 No 14.0 40.6 13.5 31.9 100.0 5,244 Characteristic Level of Health Risk Total No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 198 Table 11.3.4 Opinions Regarding the Level of Health Risk From Using Condoms by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Low Risk Medium Risk High Risk Does Not Know Total 68.1 11.9 0.7 19.3 100.0 6,292 Residence Tbilisi 76.5 11.4 0.3 11.8 100.0 1,426 Other Urban 69.0 12.2 1.3 17.6 100.0 1,549 Rural 62.7 12.1 0.6 24.6 100.0 3,317 Marital Status Married 73.4 12.3 0.8 13.5 100.0 4,098 Previously married 74.5 12.8 1.1 11.6 100.0 389 Never married 57.7 11.1 0.5 30.7 100.0 1,805 Age Group 15–19 51.6 9.4 0.6 38.4 100.0 861 20–24 65.5 12.0 0.3 22.2 100.0 1,099 25–34 73.7 12.3 0.8 13.1 100.0 2,359 35–44 73.4 13.0 0.9 12.8 100.0 1,973 Education Level Secondary incomplete or less 51.9 12.8 0.6 34.7 100.0 1,330 Secondary complete 64.7 10.8 0.6 23.9 100.0 1,568 Technicum 76.3 9.7 1.2 12.8 100.0 903 University/postgraduate 76.8 12.9 0.6 9.7 100.0 2,491 Wealth Quintile Lowest 59.4 11.9 0.5 28.1 100.0 1,093 Second 62.1 12.0 0.7 25.2 100.0 1,385 Middle 67.4 11.6 0.6 20.4 100.0 1,413 Fourth 69.4 14.5 1.4 14.7 100.0 1,037 Highest 77.1 10.2 0.4 12.2 100.0 1,364 Ethnicity Georgian 71.3 12.2 0.7 15.8 100.0 5,488 Azeri 36.1 8.4 1.1 54.4 100.0 276 Armenian 49.6 10.4 0.4 39.5 100.0 364 Other 61.4 13.0 1.5 24.1 100.0 164 Ever Used Condoms Yes 90.5 5.9 0.8 2.8 100.0 1,316 No 62.6 13.4 0.7 23.3 100.0 4,976 Characteristic Level of Health Risk Total No. of Cases FINAL REPORT 199 Table 11.3.5 Opinions Regarding the Level of Health Risk From Using Female Sterilization by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Low Risk Medium Risk High Risk Does Not Know Total 6.1 13.7 10.0 70.2 100.0 6,292 Residence Tbilisi 8.1 15.2 11.9 64.8 100.0 1,426 Other Urban 5.4 15.1 10.0 69.4 100.0 1,549 Rural 5.3 12.1 8.9 73.7 100.0 3,317 Marital Status Married 7.8 17.2 12.6 62.4 100.0 4,098 Previously married 6.0 18.7 12.5 62.9 100.0 389 Never married 3.3 6.7 5.0 85.0 100.0 1,805 Age Group 15–19 1.1 2.4 2.1 94.3 100.0 861 20–24 4.3 9.8 6.6 79.3 100.0 1,099 25–34 6.3 15.6 12.7 65.4 100.0 2,359 35–44 10.0 20.8 13.8 55.3 100.0 1,973 Education Level Secondary incomplete or less 2.0 6.9 5.1 86.0 100.0 1,330 Secondary complete 5.5 9.7 7.7 77.1 100.0 1,568 Technicum 8.8 18.6 11.0 61.5 100.0 903 University/postgraduate 8.0 18.5 13.9 59.6 100.0 2,491 Wealth Quintile Lowest 6.0 9.1 8.6 76.3 100.0 1,093 Second 4.7 11.4 9.0 74.9 100.0 1,385 Middle 5.3 14.6 9.7 70.4 100.0 1,413 Fourth 5.9 12.9 8.5 72.7 100.0 1,037 Highest 8.2 17.9 12.8 61.1 100.0 1,364 Ethnicity Georgian 6.6 14.9 10.8 67.7 100.0 5,488 Azeri 2.1 4.3 2.8 90.8 100.0 276 Armenian 3.3 3.4 4.1 89.2 100.0 364 Other 2.6 14.6 9.2 73.7 100.0 164 Ever Used Female Sterilization Yes 51.8 42.4 1.7 4.2 100.0 112 No 5.3 13.2 10.2 71.4 100.0 6,180 Characteristic Level of Health Risk Total No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 200 Table 11.3.6 Opinions Regarding the Level of Health Risk From Using Abortion on Request by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Low Risk Medium Risk High Risk Does Not Know Total 1.0 13.5 66.2 19.4 100.0 6,292 Residence Tbilisi 1.2 12.5 70.8 15.5 100.0 1,426 Other Urban 0.7 10.7 69.5 19.1 100.0 1,549 Rural 1.0 15.6 61.7 21.8 100.0 3,317 Marital Status Married 1.2 15.5 70.8 12.4 100.0 4,098 Previously married 1.4 14.9 68.3 15.4 100.0 389 Never married 0.6 9.7 57.8 32.0 100.0 1,805 Age Group 15–19 0.5 10.4 49.1 40.0 100.0 861 20–24 0.8 11.9 64.6 22.7 100.0 1,099 25–34 1.1 14.2 71.1 13.6 100.0 2,359 35–44 1.2 15.5 71.9 11.4 100.0 1,973 Education Level Secondary incomplete or less 0.9 13.8 52.6 32.7 100.0 1,330 Secondary complete 0.7 14.5 61.2 23.5 100.0 1,568 Technicum 0.4 14.8 70.0 14.7 100.0 903 University/postgraduate 1.4 12.2 75.8 10.6 100.0 2,491 Wealth Quintile Lowest 1.2 18.5 56.5 23.9 100.0 1,093 Second 0.8 14.3 63.0 21.8 100.0 1,385 Middle 1.0 14.1 65.9 19.0 100.0 1,413 Fourth 1.3 11.4 69.1 18.2 100.0 1,037 Highest 0.8 11.0 72.1 16.1 100.0 1,364 Ethnicity Georgian 0.9 12.9 69.2 17.0 100.0 5,488 Azeri 2.4 17.7 37.3 42.6 100.0 276 Armenian 0.8 17.1 51.7 30.4 100.0 364 Other 0.2 16.6 52.7 30.5 100.0 164 Used Any Method Yes 1.1 17.1 73.5 8.3 100.0 3,170 No 0.9 10.3 59.8 29.0 100.0 3,122 Level of Health Risk Characteristic Total No. of Cases FINAL REPORT 201 Table 11.4.1 Desire for More Information About Methods of Contraception By Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Yes No Does Not Know Total 53.2 42.9 3.9 100.0 6,292 Residence Tbilisi 54.2 43.2 2.5 100.0 1,426 Other Urban 55.9 41.3 2.8 100.0 1,549 Rural 51.2 43.5 5.3 100.0 3,317 Marital Status Married 53.9 43.4 2.7 100.0 4,098 Previously married 28.9 67.6 3.5 100.0 389 Never married 56.7 37.2 6.1 100.0 1,805 Age Group 15–19 62.0 29.8 8.2 100.0 861 20–24 66.8 28.8 4.4 100.0 1,099 25–34 56.7 40.2 3.1 100.0 2,359 35–44 35.6 62.4 2.0 100.0 1,973 Number of Living Children 0 56.8 37.5 5.8 100.0 2,276 1 58.2 39.4 2.4 100.0 1,286 2 48.7 48.8 2.6 100.0 2,069 3 or more 42.7 54.2 3.1 100.0 661 Education Level Secondary incomplete or less 46.6 45.2 8.2 100.0 1,330 Secondary complete 56.0 39.7 4.3 100.0 1,568 Technicum 52.8 45.6 1.6 100.0 903 University/postgraduate 55.4 42.6 1.9 100.0 2,491 Wealth Quintile Lowest 48.6 46.2 5.2 100.0 1,093 Second 51.5 42.8 5.8 100.0 1,385 Middle 53.1 42.5 4.4 100.0 1,413 Fourth 52.4 45.2 2.4 100.0 1,037 Highest 57.8 39.8 2.4 100.0 1,364 Ethnicity Georgian 54.2 42.7 3.1 100.0 5,488 Azeri 33.3 51.2 15.5 100.0 276 Armenian 60.1 33.5 6.4 100.0 364 Other 47.0 49.8 3.2 100.0 164 Ever Used Oral Contraceptives Yes 58.7 39.3 1.9 100.0 716 No 52.6 43.3 4.1 100.0 5,576 Characteristic Desired More Information Total No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 202 Table 11.4.2 Opinions Regarding the Best Source of Information about Methods of Contraception By Selected Characteristics Among All Women Aged 15–44 Who Desire More Information Reproductive Health Survey: Georgia, 2010 Gynecologist Radio/TV Newspapers/Magazines Books Friends, Peers, Contraceptive User Internet Mother Other or Unknown Total 51.5 19.8 9.6 8.9 2.6 2.6 1.9 3.2 100.0 3,441 Residence Tbilisi 54.6 15.9 7.7 10.5 2.4 4.6 2.1 2.3 100.0 776 Other Urban 51.0 20.5 11.8 6.6 2.1 3.6 1.7 2.5 100.0 893 Rural 49.9 21.8 9.4 9.2 2.9 0.7 1.8 4.2 100.0 1,772 Marital Status Married 61.1 17.6 8.4 7.0 1.7 1.4 0.1 2.6 100.0 2,277 Previously married 59.0 14.0 4.9 12.3 5.0 3.2 0.0 1.6 100.0 108 Never married 35.1 24.1 11.9 11.7 3.7 4.3 5.0 4.4 100.0 1,056 Age Group 15–19 36.6 22.6 10.4 9.8 4.8 4.1 6.4 5.4 100.0 549 20–24 51.5 20.3 9.5 8.6 2.1 3.8 1.4 2.9 100.0 767 25–34 60.4 18.1 8.5 6.8 1.6 1.7 0.6 2.4 100.0 1,383 35–44 51.6 19.4 10.6 11.9 2.5 1.1 0.2 2.7 100.0 742 Education Level Secondary incomplete or less 41.0 23.6 7.5 9.5 4.0 2.7 5.0 6.8 100.0 620 Secondary complete 52.8 21.4 11.0 6.6 3.6 1.3 1.3 1.9 100.0 895 Technicum 53.6 22.0 8.9 10.8 2.1 0.2 0.6 1.7 100.0 496 University/ postgraduate 55.1 16.3 9.9 9.4 1.3 4.1 1.2 2.7 100.0 1,430 Wealth Quintile Lowest 43.4 23.2 11.5 8.9 3.7 0.1 2.7 6.4 100.0 542 Second 51.2 22.8 7.4 9.2 3.0 1.2 1.8 3.6 100.0 747 Middle 54.0 20.8 10.4 8.3 2.4 0.9 0.6 2.7 100.0 792 Fourth 53.6 19.5 10.7 7.2 1.8 2.6 2.2 2.5 100.0 572 Highest 52.4 15.7 8.7 10.2 2.4 5.9 2.4 2.3 100.0 788 Employment Working 49.3 18.7 11.1 13.0 2.3 3.2 0.4 2.1 100.0 763 Not working 52.1 20.1 9.2 7.8 2.6 2.4 2.3 3.5 100.0 2,678 Ethnicity Georgian 51.5 19.4 9.9 9.1 2.4 2.8 2.0 3.0 100.0 3,036 Azeri 56.1 24.6 4.4 0.9 2.6 0.0 0.9 10.4 100.0 93 Armenian 51.1 22.4 7.6 10.4 3.7 0.5 1.9 2.5 100.0 235 Other 48.3 21.7 9.9 7.6 6.4 3.4 0.0 2.7 100.0 77 Used Any Method Yes 60.9 17.2 9.0 7.1 1.8 1.8 0.1 2.1 100.0 1,736 No 43.6 22.1 10.0 10.4 3.2 3.2 3.4 4.1 100.0 1,705 No. of CasesCharacteristic Best Source of Information about Methods of Contraception Total FINAL REPORT 203 Table 11.4.3 Opinions Regarding Whether Information about Methods of Contraception Should be Broadcast on Radio or Television by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Yes No Does Not Know Total 67.1 26.7 6.1 100.0 6,292 Residence Tbilisi 71.9 24.6 3.5 100.0 1,426 Other Urban 72.3 23.5 4.2 100.0 1,549 Rural 61.6 29.7 8.7 100.0 3,317 Marital Status Married 68.5 25.1 6.4 100.0 4,098 Previously married 59.5 34.6 5.9 100.0 389 Never married 66.3 27.9 5.8 100.0 1,805 Age Group 15–19 65.2 27.0 7.8 100.0 861 20–24 71.8 21.9 6.3 100.0 1,099 25–34 69.2 24.8 6.1 100.0 2,359 35–44 63.2 31.7 5.1 100.0 1,973 Education Level Secondary incomplete or less 55.9 32.0 12.1 100.0 1,330 Secondary complete 67.3 26.7 6.0 100.0 1,568 Technicum 69.4 26.6 4.0 100.0 903 University/postgraduate 72.8 23.8 3.5 100.0 2,491 Wealth Quintile Lowest 56.1 31.7 12.2 100.0 1,093 Second 61.6 30.4 8.0 100.0 1,385 Middle 69.2 25.4 5.4 100.0 1,413 Fourth 68.9 26.7 4.4 100.0 1,037 Highest 74.5 22.3 3.2 100.0 1,364 Employment Working 72.1 24.8 3.0 100.0 1,410 Not working 65.8 27.2 7.0 100.0 4,882 Ethnicity Georgian 69.0 26.7 4.3 100.0 5,488 Azeri 34.5 36.6 29.0 100.0 276 Armenian 72.0 16.2 11.9 100.0 364 Other 59.9 29.4 10.7 100.0 164 Ever used Oral Contraceptives Yes 71.7 24.7 3.6 100.0 716 No 66.6 26.9 6.4 100.0 5,576 Total No. of CasesCharacteristic "Should Information about Methods of Contraception Be Broadcast?" REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 204 205 CHAPTER 12 REPRODUCTIVE HEALTH KNOWLEDGE AND OPINIONS The reproductive health survey of Georgia incorpo- rated questions that describe women’s knowledge, attitudes, and opinions on certain reproductive health topics. According to the study results, women’s opin- ion on the ideal number of children during 11 years (from 1999 to 2010) has been remained stable at three. Correct knowledge on the contraceptive effect of breastfeeding increased after 1999, while the per- centage of women correctly knowing when the high- est risk for getting pregnant is during the menstrual cycle slightly declined. Women’s attitudes on the ac- ceptability of abortion are very important, since for a long time period in Georgia abortion has been consid- ered as a main opportunity to resolve an unwanted pregnancy. Acceptance of a woman’s own right to de- cide about her pregnancy, including abortion, is still high in Georgia, as well as in the former Soviet Union countries. According to Georgian law abortion is still allowed if the pregnancy does not exceed 12 weeks. On January first, 2011, a new regulation was estab- lished, according to which gynecologists must have a conversation concerning abortion with a pregnant women who desires an abortion; then after three days she can proceed with the abortion if she wishes. The regulation prohibits abortion after 12 weeks, as well as the advertising of abortion. 12.1 Ideal Family Size All respondents were asked about their opinion con- cerning the “ideal” number of children for a young fam- ily in Georgia. Nearly two-third (67%) of respondents stated that a young couple should have two or three children, with 47% favoring three children. About 10% of surveyed women responded that a young couple should have as many children as possible, and 6% said that a young couple should have as many as God gives (Table 12.1). These figures did not vary greatly across subgroups, except that a high 17% of the Azeri group said “As Many as Possible” while the Armenian group seldom said that and instead had a high 30% favoring an ideal of only two children. In addition, the ideal size was elevated among women with three or more children already, which may reflect their own lifetime experiences. Only seven percent favored an ideal of two children whereas 77% favored ideals of three to five or more and another 14% chose responses of “as many as God Gives” or “As Many as Possible.” The same figures were only 64% and 13% respectively among women with two living children currently. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 206 12.2 Knowledge of the Menstrual Cycle Respondents were asked their opinion as to when a woman is most likely to get pregnant during the men- strual cycle. Approximately 19% of married women use a traditional method of contraception, such as withdrawal and the rhythm method (Table 8.2.1). To use the rhythm method successfully, women should know when during the menstrual cycle they are most likely to get pregnant. According to the results, only 41% of the respondents correctly answered that the highest risk of becoming pregnant is halfway be- tween two menstrual periods. Accuracy was highest in urban areas and among ever-married women, and was directly correlated with educational attainment, wealth quintile, and age. It was remarkably low in the three groups of the youngest women, those with no children yet, and those never married, all of which had menstruated for years but for whom the rhythm method was not yet relevant. Notably, even among the best educated women only about half gave an ac- curate answer. Overall, 29% answered that they did not know when the risk is highest, but with significant variations. Again, the youngest women, those never-married women, and those children gave high “Don’t Know” replies, as did women with less education and Azeri women; half of all these groups said they did not now (Table 12.2). These results are dramatic in reflecting a need for improvement in sex education efforts. The time trends are discouraging for correct knowl- edge of when the risk of getting pregnant is the high- est. The percent giving the correct answer declined between 2005 and 2010 at every educational level, even though it had increased between 1999 and 2005 (Figure 12.2.1). It also declined from 1999 to 2010 for every age group, and most sharply for young women, at ages 15-19 and 20-24 (Figure 12.2.2). It is reason- able that correct knowledge about the menstrual cycle correlates positively with education, age, living children, marital status, wealth quintile, and urban residence, but the levels are too low and the trend is negative. Some of this explained because educational activities for reproductive health face barriers from the conservative elements of the society, and perhaps also because traditional methods of contraception are being replaced by modern methods and women are paying less attention to the chances of becoming pregnant during the menstrual cycle. (Among mar- ried women aged 15-44 the percentage using mod- ern methods rose, from 1999 to 2005 to 2010, from 19.8% to 26.6% to 34.7%, while the percentage using traditional methods was 20.7%, 20.7%, 18.5% respec- tively.) Figure 12.2.1 100 80 60 40 20 0 Percent Level of Education 1999 2005 2010 Correct Knowledge of When a Women is Most Likely to Become Pregnant During the menstrual Cycle by Education: 1999, 2005 and 2010 Secondary Incomplete Secondary Complete Technicum University 14 20 19 40 45 38 56 60 53 59 57 52 Figure 12.2.2 100 80 60 40 20 0 Percent 1999 2010 Correct Knowledge of When a Women is Most Likely to Become Pregnant During the menstrual Cycle by Age Group: 1999 and 2010 15-19 20-24 25-29 30-34 35-39 40-44 14 9 38 31 49 45 56 52 59 57 59 59 Age Group FINAL REPORT 207 12.3 Knowledge of the Contraceptive Effect of Breastfeeding Women were asked if in their opinion breastfeeding increases, decreases, or has no effect on a woman’s chance of becoming pregnant. Nearly two-thirds (59%) of women correctly answered that the risk of pregnancy is lower during breastfeeding (Table 12.3). Another 17% said it has no effect, and essentially no- one said it increases the risk. However 23% said they did not know what kind of effect breastfeeding has on fertility, and that percentage was far higher among the never married, the youngest women, those with no children, those with least education, and those in the Azeri group. On the other hand, the “Don’t Know” percentage was least (8%) and the correct reply (73%) was best among the group for which breastfeeding is most relevant, the currently married group. Accuracy was remarkably better above age 25 (Figure 12.3) and in the two higher education groups. Little difference was found among women according to resi- dence and wealth quintile. Compared to 1999, in 2010 the percentage of wom- en correctly reporting the contraceptive effect of breastfeeding increased from 56% to 60%, but it is three percentage points lower than in 2005. In ad- dition, the proportion of women who did not know whether breastfeeding influences women’s fertility changed from 25% in 1999 to 19% in 2005 and back up to 23% in 2010. This is the same time trend pattern as observed for knowledge of high-risk during men- struation (above), first increasing from 1999 to 2005 and then declining by 2010. Some of this can prob- ably be explained by the intensive and effective infor- mation campaign on the advantages of breastfeeding conducted from 1995 to 2004. Currently, both Table 12.2 and Table 12.3 show that sex education efforts must be targeted more energetically toward women aged 15-24 years old, Azeri women, and women with low educational attainment (secondary incomplete or less). 12.4 Opinions on the Acceptability of Abortion The respondents’ positions on abortion were explored by asking if “a woman should always have the right to decide about her pregnancy, including whether or not to have an abortion.” Respondents who said “No” were then asked under what specific circumstances it would be acceptable to have an abortion (Table 12.4.1). Overall, 72% of respondents agreed that a woman should always have the right to decide about her pregnancy, including resorting to abortion. Less than three percent of women opposed pregnancy termination under any circumstance whatever, while 24% considered abortion acceptable under certain cir- cumstances. The acceptability of abortion “always” increased with age and number of living children. The pattern is irregular according to educational attainment and wealth quintile, as well as by residence. All subgroups had high percentages on this item, but those who were less likely to agree with “always” included those aged 15-19 years (65%), never-married women (66%), those living in Tbilisi (66%) and women with no living children (66%). The opposite percentage, for those saying abortion was never acceptable, was below four percent in all subgroups, and the “don’t know” per- centages were nearly trivial. The percentage saying that abortion was accept- able only under certain circumstances varied around the average of 24%, being highest in the same three groups that often in these analyses show a common pattern: the youngest age group, those never-mar- ried, and those with no children yet. About 30% in each group favored abortion only under certain cir- cumstances. Tbilisi residents were also at 31%. The percentage increased generally with wealth quintile except at the next to highest level. Those respondents who said that abortion is accept- able only under certain circumstances were read a list of possible circumstances and asked to judge each on Figure 12.2.3 100 80 60 40 20 0 Percent 1999 2010 Correct Knowledge That Breastfeeding Decreases a Women's Chance of Becoming Pregnant by Age Group: 1999 and 2010 15-19 20-24 25-29 30-34 35-39 40-44 28 22 55 54 55 66 63 72 67 73 67 73 Age Group REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 208 acceptability by responding by “yes,” “no,” “depends,” or “don’t know.” Three main reasons were men- tioned under which a pregnant woman could have an abortion (Table 12.4.2). The highest “yes” percentage (77%) was when the pregnancy endangers the life of the mother, followed by 60% if the fetus has a physical deformity, and 55% if the pregnancy would endanger the woman’s health. Less than a one-third (29%) con- sidered abortion acceptable when the pregnancy re- sulted from rape. Smaller percentages were recorded for cases in which the couple cannot afford a(nother) child (11%) or where they desire no more children (7%), or if the women is not married (9%). In general the reverse of all these percentages fell into the “not acceptable” category, since the percentages saying “depends” were only 5% to 8% and the “don’t know” percentages were all below 4% with one exception. Thus it is clear that for the majority of women abor- tion is acceptable if the pregnancy endangers the woman’s life, no matter what subgroup is considered (Table 12.4.3). That is also true for the percentage concerning a fetus with physical deformities, for which the average was 60% and the lowest percentage was 56%-57% for such groups as the youngest women, the never married, and those with either no children or three or more children. Compared to Georgian wom- en, Azeri and Armenian women are twice as likely to consider abortion acceptable when the woman is un- married. Probably this reflects the influences of tradi- tional views on the subject. All respondents, regardless of their opinion about a woman’s right to decide about her pregnancy, were asked, “If a woman has an unwanted pregnancy, should she keep the baby, give the baby up to adop- tion, or have an abortion?” As shown in Table 12.4.4, about one-third of respondents said that the woman should have an abortion, while two-thirds said the woman should give birth and keep the baby. Only two percent said that the woman should have the baby and give it up for adoption. This confirms that in Geor- gia, for unwanted pregnancies, most women of child- bearing age feel that most should be carried to birth (two thirds) and most of the rest should be terminated by abortion. Those less likely to favor abortion as an option were again the usual threesome of never-mar- ried women, young women aged 15-19, and women with no living children, groups that of course overlap considerably. High education women were also less likely to favor the abortion outcome. The most remarkable result however was the very high percentages favoring abortion among the Azeri, Figure 12.4.1 100 80 60 40 20 0 Percent 1999 2010 Percentage of All Women Aged 15-44 Who Believe That Abortion is Always acceptable by Age Group: 1999 and 2010 15-19 20-24 25-29 30-34 35-39 40-44 28 22 Age Group 69 65 79 71 79 72 82 75 85 75 82 78 Figure 12.4.2 100 80 60 40 20 0 Percent 1999 2010 Circumstances Under Which Abortion is Acceptable among Women Aged 15-44 Who Said That Abortion is not Always Acceptable: 1999, 2005, and 2010 Malformed Fetus Women’s Life is Endangered Women’s Health is Endengered Pregnancy is Result of Rape Cannot Afford the Child Woman is Unmarried Circumstances 80 76 60 80 79 76 70 57 55 40 32 28 23 18 12 22 15 9 2005 FINAL REPORT 209 Armenian, and “other” ethnic groups, at 52%, 39%, and 49% respectively. That again must somehow re- flect traditional cultural effects, perhaps along with greater poverty. The trend since 2005 shows that the percentage of women who believe that abortion is always accepta- ble is ten percentage points lower than in 2005 (72.4% vs. 81.7% in 2005). That is balanced by an increase of eight percentage points in those saying it is acceptable only under certain circumstances (24.2% vs. 15.9% in 2005). The decline in the percentage favoring abortion as al- ways acceptable is displayed in Figure 12.4.1. It shows the decline in every age group that occurred between the 1999 and 2010 surveys. The decline varied be- tween 4 to 10 percentage points depending upon the age group. Marked declines also occurred in the percentage view- ing each circumstance as justifying an abortion (Figure 12.4.2). It shows the systematic, large declines for every justification, from 1999 to 2005 to 2010 in the percentage of respondents in 1999, 2005 and in 2010 who agreed that abortion is acceptable under certain circumstances. The most remarkable change however is in Figure 12.4.3. A decline of a full 38 points (68% to 30%) oc- curred in the percentage feeling that a woman with an unwanted pregnancy should have an abortion. A parallel increase of 38 points (28% to 66%) occurred in the percentage saying she should keep the baby. Those are truly historic shifts in public opinion and are more believable since the declines occurred in each five-year period. These should undoubtedly be re- garded as positive trends. 12.5 Attitudes and Opinions toward Family and Reproductive Roles All respondents were asked if they agreed with some statements reflecting reproductive roles and women’s rights and responsibilities within the family. Overall, 74% of respondents agreed that “all people should marry” (Table 12.5.1). Among ethnic groups, Azeri women showed the highest endorsement (89%). Previously married women were less likely to en- dorse universal marriage (65%), compared to married women (76%) and never-married women (74%). A sig- nificant difference in endorsement occurred between women living in Tbilisi (65%) versus those outside Tbi- lisi (over 74%). Endorsement rose regularly by num- ber of children, but fell regularly with higher educa- tion and higher wealth quintiles. About four-fifth of respondents (78%) agreed that “a woman must be a virgin at marriage.” This conservative view is more prevalent among women living outside Tbilisi, young women aged 15-24 years, women with three or more children, those with less education, and those in the low and middle wealth quintiles, as well as among Azeri and Armenian women. In general, 72% of respondents agreed that “child care is a women’s job” (Figure 12.5.1). The subgroup pat- terns are largely similar to those just above regarding virginity. Rural women, women with more children, those with lower educational attainments and wealth quintiles, as well as Azeri and Armenian women were most likely to endorse this statement. On an- other topic, 74% of respondents agreed that “women should have as many children as God gives them.” The high rates of endorsement of this traditional attitude were among never-married women, women aged 15-24 years, women with no living children, women with the highest level of education, and those in the fourth highest quintile. Azeri, Armenian, and “other” ethnic groups are notable for the low endorsements they gave to this item, which is consistent with their greater endorsement of abortion seen above. Other patterns are somewhat irregular, and are somewhat difficult to explain. It can be assumed that in the re- cent period religious women are equally represented in all layers of society. Four additional questions (on risk of pregnancy at first intercourse, refusal of sex if a husband has an STI, ac- Figure 12.4.3 100 80 60 40 20 0 Percent 1999 2010 Opinions Regarding What a Women Should Do if a Pregnancy is Unwanted Among Women Aged 15-44: 1999, 2005, and 2010 Have Abortion Opinion 2005 68 55 30 28 42 66 1 2 3231 Keep Baby Adoption Don’t Know REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 210 ceptability of asking a husband to use a condom if he has an STI, and whether a good wife obeys her hus- band) were asked of all respondents. The vast ma- jority (84%) agreed that a woman can become preg- nant during first sexual intercourse. The subgroups of women least likely (73% and less) to agree with this statement were women aged 15-24 years, never mar- ried women, women with no children and those with a secondary incomplete or lower education (Table 12.5.1). A majority (76%) also agreed that “a woman can re- fuse sex with her husband if he has an STI” and that “a woman can ask her husband to use a condom when they have sex if he has an STI” (74%). Never-married women, women aged 15-24 years, women with sec- ondary incomplete or less education, and Azeri wom- en were the least likely to agree with these two state- ments. By far, most women residing in Tbilisi (81%) agreed that “a woman can ask her husband to use a condom…”, whereas only 68% of women from rural areas agreed with this statement. Agreement for both questions was least among the unmarried, young- est, and childless groups, and the Azeri and Armenian groups. It declined systematically toward less edu- cation and toward the poorest quintiles. In general, knowledge regarding sexual and reproductive health correlates with less education and to some extent with life experience and the related groups should be considered as a focus for conducting educational activities. They also appear to need special programs aimed at improving communication with sexual part- ners. Respondents were asked about agreement with the statement that “A good wife obeys her husband.” Only 42% agreed, the lowest concurrence among all items in Table 12.5.1. A mere 26% of Tbilisi women agreed, only 34% in the top education group did so, and only 28% in the top wealth quintile did so. The expected patterns also by age and number of children appeared, all along the lines of greater independence for women during social change in Georgia. Finally, all study participants were asked, “Who do you think should decide how many children a couple should have?” The vast majority of respondents (94%) said that a man and a woman should make that deci- sion together. All other percentages were low (3% to 6%), with little variation among subgroups. Less than 2% of the women stated that the man should make the decision, except for about 6% in the Azeri group (Table 12.5.2). The trends are interesting for some of the above find- ings, and they reflect the social changes underway in Georgia (Figure 12.5.1). Between 1999 and 2010 the percentage of women who agreed that “child care is a women’s job” declined, as did the percentage insisting on virginity at marriage, or that every indi- vidual should get married, although all percentages remained at high levels. In contrast there was a very sharp increase, of 23 points, in the percentage say- ing women must have the children that God gives to them. That seems consistent with the declines in the percentage favoring abortion on demand. Clearly, an emancipation process is underway in Geor- gia. At the same time, human values are strengthen- ing, while a dislike of abortion is increasing. During these processes a positive influence of religion in the post-soviet period should play an important role. The surveys show that the foundation of the family and having children are the most significant values for women living in Georgia. It is worth noting that vari- ous awareness-raising and educational projects im- plemented by the UNFPA during the last decade could have had greater effects if not hindered by the reac- tionary groups during negative TV talk-shows, while constructive health-related informational and educa- tional programs on TV including those on reproduc- tive health are minimized. Figure 12.5.1 100 80 60 40 20 0 Percent 1999 2010 Agreement with Various Statements on Reproductive Norms Among Women Aged 15-44: 1999, 2005, and 2010 Child Care is a Woman’s Job 2005 Women should be Virgins at the Marriage Every Individual Should Get Married Women Must Have the Children That God Gives Them 88 73 72 85 77 78 84 82 74 51 62 74 FINAL REPORT 211 Table 12.1 Opinions Regarding the Ideal Number of Children for a Young Family in Georgia by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 0–1 2 3 4 5 or More As Many as God Gives As Many as Possible Not Sure Mean No. of Cases * Total 0.7 19.8 47.1 12.3 2.3 5.8 9.9 2.1 100.0 6,292 3.0 5,159 Residence Tbilisi 0.8 19.5 49.0 13.1 1.8 5.6 8.8 1.4 100.0 1,426 3.0 1,203 Other Urban 1.0 22.0 45.1 11.3 2.6 6.1 10.4 1.6 100.0 1,549 2.9 1,255 Rural 0.4 18.8 47.0 12.3 2.4 5.9 10.4 2.9 100.0 3,317 3.0 2,701 Marital Status Married 0.6 18.6 49.5 13.0 2.2 4.4 10.1 1.5 100.0 4,098 3.0 3,416 Previously married 0.8 23.4 40.0 10.5 2.4 6.6 13.0 3.3 100.0 389 2.9 304 Never married 0.9 21.1 44.1 11.3 2.4 8.1 9.1 2.9 100.0 1,805 2.9 1,439 Age Group 15–19 0.6 21.8 44.8 10.6 2.2 7.3 8.9 3.8 100.0 861 2.9 691 20–24 0.8 21.2 49.6 10.1 2.2 4.9 8.4 2.7 100.0 1,099 2.9 929 25–34 0.6 19.5 47.0 12.6 2.1 5.4 11.4 1.5 100.0 2,359 3.0 1,927 35–44 0.7 18.1 46.8 14.3 2.6 6.1 9.9 1.5 100.0 1,973 3.0 1,612 Number of Living Children Total No. of Cases Mean No. of Children Characteristic Ideal Number of Children Living Children 0 0.8 20.9 44.4 11.3 2.3 8.6 9.0 2.7 100.0 2,276 2.9 1,805 1 0.9 23.0 47.3 9.6 1.2 4.8 11.2 1.9 100.0 1,286 2.8 1,063 2 0.3 20.7 48.1 13.7 1.8 2.8 10.8 1.7 100.0 2,069 3.0 1,744 3 or more 0.6 6.8 54.2 17.0 5.8 5.3 9.0 1.3 100.0 661 3.3 547 Education Level Secondary incomplete or less 0.6 22.2 43.2 11.7 2.4 5.6 9.4 4.9 100.0 1,330 2.9 1,070 Secondary complete 1.1 19.0 46.6 13.0 2.5 5.6 9.8 2.5 100.0 1,568 3.0 1,284 Technicum 0.3 20.4 49.4 11.1 1.7 5.2 10.7 1.3 100.0 903 3.0 746 University/ postgraduate 0.6 18.8 48.7 12.6 2.2 6.4 10.1 0.6 100.0 2,491 3.0 2,059 Wealth Quintile Lowest 0.4 19.2 41.0 14.2 2.9 5.8 11.9 4.7 100.0 1,093 3.0 839 Second 0.5 18.9 49.5 10.7 2.0 5.1 10.6 2.7 100.0 1,385 3.0 1,148 Middle 0.7 19.4 47.4 12.5 2.2 6.8 9.6 1.5 100.0 1,413 3.0 1,164 Fourth 0.9 23.7 43.5 11.6 2.5 6.3 9.9 1.7 100.0 1,037 2.9 850 Highest 0.9 18.4 50.9 12.8 2.0 5.4 8.7 1.1 100.0 1,364 3.0 1,158 Ethnicity Georgian 0.7 19.2 47.7 12.7 2.4 6.4 9.9 1.1 100.0 5,488 3.0 4,519 Azeri 0.3 19.4 39.0 7.5 1.6 3.0 17.3 11.9 100.0 276 2.9 186 Armenian 1.5 30.1 48.1 9.3 1.4 0.9 3.1 5.7 100.0 364 2.8 328 Other 0.0 20.3 38.6 14.8 2.6 4.0 10.7 9.0 100.0 164 3.0 126 * Excludes 1,133 women who gave non–numeric answers. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 212 Table 12.2 Opinions Regarding When a Woman is Most Likely to Become Pregnant During Her Menstrual Cycle by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Just Before Her Period Starts During Her Period Right After Her Period Ends Halfway Between Her Periods Anytime Don't Know Total 3.1 0.3 18.5 41.1 7.6 29.4 100.0 6,292 Residence Tbilisi 3.6 0.4 19.0 46.2 6.8 24.0 100.0 1,426 Other Urban 2.1 0.4 18.3 44.7 7.8 26.7 100.0 1,549 Rural 3.4 0.3 18.3 36.1 8.0 34.0 100.0 3,317 Marital Status Married 3.3 0.2 21.3 54.5 6.5 14.2 100.0 4,098 Previously married 1.6 0.9 18.5 57.1 6.8 15.0 100.0 389 Never married 3.1 0.5 13.6 14.8 9.7 58.2 100.0 1,805 Age Group 15–19 3.0 0.2 9.1 9.3 10.2 68.2 100.0 861 20–24 2.9 0.4 19.9 31.3 9.1 36.5 100.0 1,099 25–34 3.5 0.3 21.6 48.5 7.2 18.9 100.0 2,359 35–44 3.0 0.5 19.9 57.9 5.7 13.1 100.0 1,973 Number of Living Children 0 3.0 0.5 14.5 19.8 9.3 52.9 100.0 2,276 1 2.6 0.2 21.8 55.2 6.7 13.5 100.0 1,286 2 3.5 0.1 21.7 56.5 5.8 12.4 100.0 2,069 3 or more 3.5 0.7 19.6 55.9 7.6 12.7 100.0 661 Education Level t Secondary incomplete or less 2.4 0.6 15.4 19.3 9.5 52.8 100.0 1,330 Secondary complete 5.4 0.2 16.8 37.6 8.2 31.7 100.0 1,568 Technicum 2.5 0.4 23.4 53.0 5.6 15.0 100.0 903 University/ postgraduate 2.3 0.2 19.7 51.7 6.8 19.2 100.0 2,491 Wealth Quintile Lowest 2.9 0.4 17.3 32.8 5.8 40.8 100.0 1,093 Second 4.2 0.2 20.1 35.0 8.2 32.3 100.0 1,385 Middle 3.1 0.3 18.2 37.6 9.9 30.9 100.0 1,413 Fourth 3.0 0.6 17.1 45.4 7.2 26.6 100.0 1,037 Highest 2.5 0.3 19.2 50.0 6.6 21.4 100.0 1,364 Ethnicity Georgian 3.2 0.4 19.3 42.7 7.0 27.4 100.0 5,488 Azeri 1.7 0.0 11.4 20.8 12.3 53.8 100.0 276 Armenian 3.1 0.0 13.7 34.0 11.1 38.1 100.0 364 Other 3.3 0.0 16.5 40.4 10.5 29.3 100.0 164 No. of CasesCharacteristic When is a Women Most Likely to Became Pregnant? Total FINAL REPORT 213 Table 12.3 Opinions Regarding Whether Breastfeeding Increases, Decreases, or Has No Effect on a Woman's Chances of Becoming Pregnant by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Increases the Chance Decreases the Chance Has No Effect Don't Know Total 0.6 59.0 17.3 23.1 100.0 6,292 Residence Tbilisi 0.9 59.5 20.2 19.4 100.0 1,426 Other Urban 0.2 61.1 17.8 21.0 100.0 1,549 Rural 0.7 57.6 15.3 26.3 100.0 3,317 Marital Status Married 0.7 73.3 18.0 8.0 100.0 4,098 Previously married 0.4 68.1 18.7 12.9 100.0 389 Never married 0.6 32.6 15.8 50.9 100.0 1,805 Age Group 15–19 0.5 22.0 14.7 62.7 100.0 861 20–24 0.6 54.0 16.8 28.6 100.0 1,099 25–34 0.7 69.3 18.4 11.6 100.0 2,359 35–44 0.6 72.9 18.0 8.5 100.0 1,973 Number of Living Children 0 0.7 36.2 16.5 46.7 100.0 2,276 1 0.7 74.5 17.8 7.0 100.0 1,286 2 0.6 75.2 18.1 6.0 100.0 2,069 3 or more 0.5 75.6 17.4 6.5 100.0 661 Education Level Secondary incomplete or less 0.6 42.6 14.8 42.0 100.0 1,330 Secondary complete 0.6 56.5 16.6 26.3 100.0 1,568 Technicum 0.6 70.9 19.4 9.1 100.0 903 University/postgraduate 0.7 66.0 18.4 14.8 100.0 2,491 Wealth Quintile Lowest 0.5 55.2 15.5 28.8 100.0 1,093 Second 0.6 58.7 14.6 26.0 100.0 1,385 Middle 1.0 57.0 16.9 25.1 100.0 1,413 Fourth 0.2 62.3 17.3 20.1 100.0 1,037 Highest 0.7 60.6 20.7 18.0 100.0 1,364 Ethnicity Georgian 0.6 60.7 17.6 21.2 100.0 5,488 Azeri 0.0 41.5 15.5 43.0 100.0 276 Armenian 1.6 48.0 14.6 35.8 100.0 364 Other 2.1 59.3 17.8 20.8 100.0 164 Characteristic Total No. of Cases How Does Breastfeeding Affect a Woman's Chance of Getting Pregnant? REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 214 Table 12.4.1 Opinions Regarding the Acceptability of Abortion by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Always Acceptable Acceptable Under Certain Circumstances Never Acceptable Does Not Know Total 72.4 24.2 2.9 0.5 100.0 6,292 Residence Tbilisi 65.5 30.9 3.2 0.4 100.0 1,426 Other Urban 75.1 21.1 3.6 0.2 100.0 1,549 Rural 75.0 22.0 2.2 0.7 100.0 3,317 Age Group 15–19 64.5 31.4 3.0 1.2 100.0 861 20–24 71.4 24.1 3.8 0.7 100.0 1,099 25–34 73.7 22.8 3.0 0.4 100.0 2,359 35–44 76.4 21.5 2.0 0.1 100.0 1,973 Marital Status Married 75.6 21.4 2.6 0.3 100.0 4,098 Previously married 77.7 19.4 2.7 0.2 100.0 389 Never married 65.9 29.9 3.3 0.9 100.0 1,805 Number of Living Children 0 65.6 30.3 3.3 0.8 100.0 2,276 1 74.9 21.7 3.2 0.2 100.0 1,286 2 77.9 19.4 2.4 0.3 100.0 2,069 3 or more 79.3 18.3 1.7 0.7 100.0 661 Education Level Secondary incomplete or less 75.7 21.2 2.0 1.2 100.0 1,330 Secondary complete 71.8 24.0 3.7 0.5 100.0 1,568 Technicum 74.9 22.5 2.1 0.4 100.0 903 University/postgraduate 70.1 26.7 3.1 0.2 100.0 2,491 Wealth Quintile Lowest 76.2 20.6 2.2 1.0 100.0 1,093 Second 76.9 20.6 2.0 0.5 100.0 1,385 Middle 71.2 25.0 3.1 0.7 100.0 1,413 Fourth 72.8 23.1 3.7 0.3 100.0 1,037 Highest 67.7 29.1 3.1 0.2 100.0 1,364 Ethnicity Georgian 71.6 25.0 2.9 0.4 100.0 5,488 Azeri 77.1 19.3 2.0 1.7 100.0 276 Armenian 78.9 18.1 1.8 1.2 100.0 364 Other 75.9 20.1 3.5 0.5 100.0 164 Characteristic Acceptability of Abortion Total No. of Cases FINAL REPORT 215 Table 12.4.2 Acceptable Not Acceptable Depends Don't Know If pregnancy endangers woman's life 77.2 16.1 4.4 2.4 100.0 1,689 If the fetus has a physical deformity 60.4 27.6 8.1 4.0 100.0 1,689 If pregnancy endangers women's health 55.2 34.8 6.8 3.1 100.0 1,689 If pregnancy resulted from rape 29.4 55.5 7.7 7.4 100.0 1,689 If the couple cannot afford to have a(nother) child 10.8 80.2 5.4 3.7 100.0 1,689 If the women is not married 8.8 80.1 7.2 4.0 100.0 1,689 If the couple desire no (more) children 7.2 84.6 4.9 3.3 100.0 1,689 Circumstance Acceptability of Abortion Total No. of Cases Acceptability of Abortion Under Selected Circumstances Among Women Aged 15–44 Who Do Not Believe That Abortion Is Always Acceptable Reproductive Health Survey: Georgia, 2010 Table 12.4.3 Circumstances Under Which It Is Acceptable to Have an Abortion by Selected Characteristics Among Women Aged 15–44 Who Do Not Believe That Abortion Is Always Acceptable Reproductive Health Survey: Georgia, 2010 Women's Life Endangered Fetus Deformed Women's Health Endangered Pregnancy Resulted from Rape Cannot Afford Child Women Unmarried Desires No (More) Children Total 77.2 60.4 55.2 29.4 10.8 8.8 7.2 1,689 Residence Tbilisi 81.2 57.7 56.3 26.6 10.2 4.7 6.6 483 Other Urban 71.9 57.3 51.1 29.3 9.3 10.5 3.7 381 Rural 76.8 64.2 56.7 31.6 12.0 11.1 9.6 825 Age Group 15–24 76.9 56.4 55.5 29.1 7.8 8.8 4.8 615 25–34 77.3 62.2 56.2 28.3 11.4 10.3 7.4 598 35–44 77.6 64.6 53.7 31.1 14.7 6.8 11.0 476 Marital Status Married 77.4 64.2 56.1 31.9 14.1 9.2 9.2 998 Previously married 74.3 59.9 49.0 24.3 12.0 6.1 8.0 83 Never married 77.3 55.7 55.0 26.9 6.5 8.5 4.6 608 Number of Living Children 0 77.1 56.8 54.4 27.3 6.6 7.9 4.6 773 1 74.9 64.5 59.0 27.1 14.4 8.0 8.1 334 2 80.6 66.5 57.7 34.1 16.7 10.8 11.5 446 3 or more 72.3 55.9 45.0 34.1 12.0 9.9 9.2 136 Education Level Secondary incomplete or less 77.4 60.5 59.4 34.9 11.8 13.6 9.7 319 Secondary complete 72.8 60.7 52.0 31.8 11.7 9.3 6.4 409 Technicum 80.4 69.4 60.5 35.4 16.2 11.7 10.7 217 University/ postgraduate 78.7 57.5 53.8 23.6 8.2 5.4 5.5 744 Wealth Quintile Lowest 78.6 62.7 59.0 32.7 15.3 9.6 8.3 260 Second 79.3 66.7 59.2 29.3 13.2 15.0 10.0 324 Middle 75.0 58.4 48.0 29.0 8.8 9.2 6.7 391 Fourth 75.7 60.2 56.2 25.0 5.8 5.9 3.9 282 Highest 78.0 57.5 56.4 30.9 12.1 6.5 7.6 432 Ethnicity Georgian 77.7 59.7 55.2 28.6 10.3 8.1 6.5 1,520 Azeri 68.5 67.6 53.9 47.2 16.6 16.8 18.1 60 Armenian 73.2 71.2 60.8 30.4 9.3 14.2 9.9 67 Other 78.2 54.8 49.8 25.1 17.7 10.7 11.5 42 No. of CasesCharacteristic Circumstances Under Which It Is Acceptable to Have an Abortion REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 216 Table 12.4.4 Opinions Regarding What a Woman Should Do If She Has an Unwanted Pregnancy by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Give Birth and Keep the Baby Have an Abortion Give Birth and Give the Baby Up for Adoption Does Not Know Total 65.5 29.5 2.1 2.9 100.0 6,292 Residence Tbilisi 66.1 29.4 2.5 2.0 100.0 1,426 Other Urban 70.5 25.0 1.8 2.7 100.0 1,549 Rural 62.4 32.0 2.0 3.6 100.0 3,317 Marital Status Married 60.1 35.3 1.9 2.7 100.0 4,098 Previously married 64.4 32.4 1.8 1.4 100.0 389 Never married 74.9 18.9 2.5 3.7 100.0 1,805 Age Group 15–19 72.8 19.7 2.4 5.1 100.0 861 20–24 69.2 26.1 1.8 2.8 100.0 1,099 25–34 63.4 32.1 2.0 2.5 100.0 2,359 35–44 61.0 34.6 2.2 2.2 100.0 1,973 Number of Living Children 0 75.2 18.9 2.4 3.5 100.0 2,276 1 66.2 30.9 1.5 1.5 100.0 1,286 2 55.7 38.5 2.3 3.5 100.0 2,069 3 or more 53.1 43.6 1.4 1.9 100.0 661 Education Level Secondary incomplete or less 61.5 32.4 1.7 4.4 100.0 1,330 Secondary complete 60.5 33.8 2.3 3.4 100.0 1,568 Technicum 62.6 33.1 2.3 2.0 100.0 903 University/ postgraduate 71.8 23.9 2.1 2.1 100.0 2,491 Wealth Quintile Lowest 60.3 34.2 1.4 4.1 100.0 1,093 Second 64.3 30.7 1.9 3.1 100.0 1,385 Middle 64.9 29.2 2.2 3.7 100.0 1,413 Fourth 67.2 28.3 2.5 2.0 100.0 1,037 Highest 68.6 27.1 2.3 2.1 100.0 1,364 Ethnicity Georgian 68.3 26.9 2.2 2.6 100.0 5,488 Azeri 39.2 52.3 0.9 7.6 100.0 276 Armenian 55.3 39.2 1.4 4.0 100.0 364 Other 45.6 48.8 2.4 3.1 100.0 164 No. of CasesCharacteristic What Should a Woman Do If She Has an Unwanted Pregnancy? Total FINAL REPORT 217 Table 12.5.1 Agreement with Selected Statements on Gender and Reproductive Norms by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 All people Should Marry % Women Must be Virgins at Marriage % Child Care is a Women's Job % Women Must have the Children That God Gives Them % A women Can Get Pregnant at First Sex % A women Can Refuse Sex if Her Husband Has an STI % A women Can Ask Her Husband to Use a Condom if He Has an STI % A Good Wife Obeys Her Husband % Total 74.3 77.5 72.2 73.9 84.1 76.5 73.8 42.5 6,292 Residence Tbilisi 64.6 60.8 62.1 73.1 85.4 82.8 81.1 26.5 1,426 Other Urban 74.7 80.5 71.1 76.4 86.3 78.2 76.5 41.8 1,549 Rural 79.8 85.7 78.6 72.9 82.1 71.8 68.1 52.1 3,317 Age Group 15–24 76.0 80.0 72.6 77.6 72.9 70.3 67.6 40.1 1,960 25–34 73.1 75.2 71.9 70.8 89.7 80.2 78.1 43.4 2,359 35–44 73.6 77.0 71.9 72.6 91.6 80.1 76.7 44.3 1,973 Marital Status Married 75.8 78.7 72.6 70.8 91.0 79.8 77.2 47.3 4,098 Previously married 64.7 59.1 68.1 70.4 91.4 86.5 84.4 28.5 389 Never married 73.5 78.8 72.2 79.8 70.7 68.9 66.1 36.7 1,805 Number of Living Children 0 73.8 78.3 71.9 80.1 72.8 70.9 68.0 37.9 2,276 1 72.3 71.1 69.7 72.3 91.1 83.4 82.0 41.9 1,286 2 74.7 77.5 72.2 67.0 92.5 80.5 76.9 44.9 2,069 3 or more 79.1 86.0 77.7 71.1 92.2 75.0 73.2 54.9 661 Education Level Secondary incomplete or less 81.1 84.8 80.3 72.8 71.5 65.5 63.3 51.6 1,330 Secondary complete 75.7 83.4 77.1 71.3 83.5 73.6 69.8 49.5 1,568 Technicum 75.7 79.8 73.2 72.4 90.9 81.3 78.2 39.1 903 University/ postgraduate 69.1 68.9 64.0 76.6 89.4 83.1 80.9 33.9 2,491 Wealth Quintile Lowest 79.6 85.8 79.4 73.8 78.3 73.0 69.4 56.4 1,093 Second 80.5 87.2 79.0 71.9 85.0 71.4 67.5 50.9 1,385 Middle 78.5 82.7 74.3 72.0 84.0 75.7 72.4 46.3 1,413 Fourth 70.2 76.5 73.5 77.5 84.9 77.2 75.4 38.2 1,037 Highest 66.1 61.9 60.2 74.3 86.1 82.5 81.1 28.1 1,364 Ethnicity Georgian 73.6 76.6 70.7 75.8 85.3 78.8 76.8 38.8 5,488 Azeri 88.5 92.4 87.9 60.3 73.4 52.6 44.9 84.9 276 Armenian 73.0 82.3 81.5 59.4 75.1 60.2 49.5 55.8 364 Other 72.8 67.9 70.1 65.4 83.5 78.2 79.3 51.6 164 Characteristic No. of Cases Agreement with Selected Statements on Gender and Reproductive Norms REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 218 Table 12.5.2 Opinions Regarding Who Should Decide How Many Children a Couple Will Have by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 The Woman The Man Both Does Not Know Total 4.0 0.8 94.1 1.1 100.0 6,292 Residence Tbilisi 4.9 0.4 94.0 0.7 100.0 1,426 Other Urban 2.9 0.4 95.9 0.8 100.0 1,549 Rural 4.1 1.2 93.2 1.5 100.0 3,317 Marital Status Married 3.9 1.0 94.5 0.7 100.0 4,098 Previously married 6.3 0.2 92.5 1.0 100.0 389 Never married 3.8 0.6 93.7 1.9 100.0 1,805 Age Group 15–19 4.1 0.8 93.1 2.0 100.0 861 20–24 3.0 0.8 94.4 1.8 100.0 1,099 25–34 4.0 1.0 94.4 0.6 100.0 2,359 35–44 4.6 0.6 94.2 0.6 100.0 1,973 Number of Living Children 0 3.5 0.7 94.3 1.6 100.0 2,276 1 4.7 0.5 94.1 0.7 100.0 1,286 2 4.3 0.7 94.1 0.9 100.0 2,069 3 or more 4.1 2.1 93.2 0.7 100.0 661 Education Level Secondary incomplete or less 4.3 1.8 91.2 2.7 100.0 1,330 Secondary complete 5.0 0.8 93.4 0.8 100.0 1,568 Technicum 3.5 0.5 95.5 0.5 100.0 903 University/postgraduate 3.4 0.3 95.7 0.6 100.0 2,491 Wealth Quintile Lowest 3.3 1.0 93.9 1.7 100.0 1,093 Second 4.4 1.4 93.1 1.1 100.0 1,385 Middle 3.5 0.9 93.9 1.7 100.0 1,413 Fourth 3.9 0.3 94.9 0.9 100.0 1,037 Highest 4.6 0.4 94.5 0.5 100.0 1,364 Ethnicity Georgian 3.8 0.4 94.9 0.9 100.0 5,488 Azeri 2.9 5.5 89.2 2.5 100.0 276 Armenian 5.2 2.0 89.5 3.2 100.0 364 Other 8.9 1.9 87.0 2.2 100.0 164 Characteristic Who Should Decide How Many Children a Couple Will Have? Total No. of Cases 219 CHAPTER 13 HEALTH BEHAVIORS The right health-promoting behaviors can greatly en- hance personal health and can complement formal health care. Behaviors such as getting regular exams, avoiding cigarette smoking, and drinking alcohol only in moderation are instrumental in protecting health and preventing chronic diseases. This chapter reports on important health behaviors and knowledge among women of reproductive age in Georgia. In particular, the Georgian 2010 survey explores health care utili- zation, breast and cervical cancer screening, tuber- culosis, smoking, and alcohol use. These issues are examined with attention to women’s demographic characteristics, to help explain the changing and var- ied health care needs of the various subgroups in the population. Particular attention was given to documenting pre- ventive practices that help lower the risk of breast and cervical cancer. Despite recent advances in pre- vention, diagnosis, and treatment, gynecologic ma- lignancies continue to be a leading cause of death in women of reproductive age in both the developed and developing world. Among reproductive system cancers, breast and cervical cancer are the most com- mon. Early diagnosis and treatment are essential for cancer therapy to be highly effective. Unfortunately, a substantial proportion of these cancers in Eastern Eu- rope are detected at an advanced and incurable stage as a result of several factors: women’s lack of aware- ness or reluctance to access preventive care services; provider’s lack of interest, time, or expertise for health promotion; and a health system that allocates more of its limited resources to curative care than to preven- tion. Breast cancer accounted for most deaths among women aged 15-44 in Georgia in 2006 (14%) and cervi- cal cancer ranked fourth, accounting for 5% of deaths. Crude case-specific mortality rates for breast cancer among these women was higher than the European average (7.9 per 100,000 vs. 5.4 per 100,000 women aged 15-44) (Serbanescu et al., 2009). 13.1 Utilization of Health Care Services Interactions between clients and health providers con- stitute an important opportunity for health promotion and disease prevention. During patient encounters, providers can give general health counseling and ad- vice to lessen high-risk behaviors. Patients’ attitudes and behaviors regarding health care visits are im- portant determinant of whether they receive health counseling and routine screening, including cervical and breast cancer screening. Therefore respondents were asked a series of questions that explored health care-seeking behaviors and barriers to health care. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 220 Having a “usual place” for care, a location or source where one regularly receives health care, is associat- ed with fewer delays in getting care, better preventive care, and better treatment. The majority of respond- ents (79%) reported having a usual place where they obtain their health care (Table 13.1.1). This was more often the case for women who had health insurance (85%) and those employed (83%). There appears to be a direct correlation between hav- ing a usual place of care and educational attainment. The proportion of women with a usual place for care increased with education from 73% of women who had no completed secondary school to 83% of women with university or postgraduate education. Having a consistent place for care was less common for ado- lescents aged 15-19 (71%), young adults aged 20-24 (76%), women residing in households in the lowest wealth quintile (74%), and ethnic minorities (70%). Women who reported they had a usual place for care obtained most of the care in hospitals (38%) and am- bulatory clinics (i.e. policlinics and women’s consul- tation clinics) (26%). Only a minority obtained usual care in primary health care (PHC) facilities (14%). In rural areas the most common place for usual care was a regional/city hospital (46%), while in urban areas, substantial proportions of women attended policlin- ics and women’s consultation clinics or regional/city hospitals (33% and 31% respectively) (Figure 13.1.1). Over a third of women (37%) reported that they had visited a health care facility (either for treatment or for preventive services, including family planning) dur- ing the 12 months before the interview (Table 13.1.2). That is an increase from the previous, 2005, survey, in which only a quarter (25%) of women had visited a health care facility in the past year (data not shown). Health care visits were more common among urban residents (39%), residents of Tbilisi (41%) and Imereti (43%). Of those who had at least one health visit (2353 cases in Table 13.1.2), one half (51%) were seen for acute care, 41% were seen for preventive care, and 20% were seen for care of a chronic condition (summing to over 100% due to multiple visits). Compared to their rural counterparts, a higher proportion in urban areas had preventive health visits (43% vs. 39%) and a lower proportion had acute care visits (49% vs.53%) (Figure 13.1.2). There was no urban/rural difference in the proportion who received care for chronic conditions. When asked if they had to delay getting medical care in the last 12 months, either for prevention or for an illness, a quarter (25%) of respondents reported de- lays (Table 13.1.3). The overwhelming majority of women (82%) who had delayed care reported that the cost of health care services was the most important deterrent. This was particularly true for women with multiple children (84% and higher), women with the Figure 13.1.1 100 80 60 40 20 0 Percent Urban Rural Usual Place of Health Care by Residence Among Women Aged 15-44 Years Regional/City Hospital 31 46 33 17 16 12 19 22 Polyclinic/Women’s Consultation Center NonePrimary Health Care/Family Medicine Center Figure 13.1.2 100 80 60 40 20 0 Percent Urban Rural Type of Health Care Received by Residence Among Women Aged 15-44 Who Had Used Medical Care in the Past 12 Months Prevention Care 43 39 Acute Care Chronic Care 49 53 20 20 FINAL REPORT 221 least education (91%) or in the poorest wealth quintile (90%), and ethnic minority women (91%). In this context, GERHS10 examined the health insur- ance coverage among women of reproductive age at the time of interview. A woman was defined as in- sured if either directly or through a spouse or parent she had any government-paid insurance (e.g. insur- ance for vulnerable populations --- “5 Lari” insurance), other government-sponsored health plan, or private health insurance through an employer (i.e. insurance for civil servants and governmental employees; pri- vate insurance partially funded), or self-insurance. Only 22% of women had any health insurance at the time of the interview (Table 13.1.4). This proportion varied little by urban or rural residence and was the lowest among residents of Kvemo Kartli (14%). Given the unequal geographic distribution of the population under the poverty level, insured women in rural areas were much more likely to have govern- ment-supported health insurance than urban women (70% vs. 29%) and less likely to have private insurance (Figure 13.1.3). Women aged 35 or older were slightly more likely to report being insured and more likely to have private insurance than younger women. Health insurance coverage was higher among women with post graduate education (27%), who were mostly cov- ered by private insurance, than among women with lower education (18-19%). Women residing in house- holds within the lowest wealth quintile reported higher coverage (28%) than women in other wealth groups; virtually all of them had government-funded insurance for the vulnerable population. Employed women were more than twice as likely as unemployed women to have insurance (39% vs. 18%); more than half of those with insurance had an insurance plan partially or fully supported by the employer. Twenty- four percent of Georgian women compared to only 11% of women belonging to ethnic minorities had health insurance; among insured women the source of insurance did not differ by ethnic background. 13.2 Prevalence of Routine Gynecologic Visits The American college of Obstructers and Gynecology has recently updated its guidelines to recommend that women have a routine gynecologic examination every year after age 21; however other guidelines vary throughout the world. The Georgia 2010 survey shows an increase in the proportion of women who have had routine gynecologic exams in the last year (25%, up from 20% in 2005); however, this is still low- er than in 1999 when 30% of women reported having had an exam in the last year (Table 13.2 and Figure 13.2). There was an inverse correlation between age and having had a gynecologist exam in the past 12 months, ranging from 32% of 15-24 year-olds to only 17% of 40-44 year-olds. In fact, 38% of women aged 40-44 years had their last routine gynecological exam more than three years prior to the interview and 19% had never had a routine exam. A direct relationship existed between wealth quintiles and gynecologic ex- ams, with more women in the lowest quintile never having had an exam (39%) and fewer women in the highest quintiles never having had one (21%). Since screenings for cervical and breast cancer are gener- ally provided or prescribed during routine gynecologic visits, a low prevalence of routine gynecologic exams inevitably has an impact on early detection and treat- ment of gynecologic cancers. It also has a substantial negative effect on family planning counseling and dis- semination of other health messages. 13.3 Breast Cancer Screening Breast cancer far exceeds all other cancer diagnoses among women, with an estimated 1.38 million new cancer cases globally diagnosed in 2008 (23% of all cancers), and it ranks second overall (10.9% of all can- cers). Breast cancer has become the most common Figure 13.1.3 100 80 60 40 20 0 Percent Urban Rural Main Source of Health Insurance by Residence Among Women Aged 15-44 with Health Insurance Government-Funded Private (Through Employer) Private (Self-Funded) 29 70 42 23 29 7 Note: Rates are age-standardized, so they permit international comparisons regardless of varying age struc- tures. Source: Ferlay J, et al,. Cancer Incidence and Mortality Worldwide: IARC Cancer Base No 10, 2010 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 222 cancer both in developed and developing regions with approximately 690,000 new cases estimated in each region (population ratio 1:4) (Ferlay et al., 2010). The age-standardized incidence rate of reported new cases of breast cancer in Georgia (38.5 new cases per 100,000 women is higher than elsewhere in West- ern Asia (as categorized in GLOBOCAN 2008 cancer registry) but it is lower than the averages in Central and Eastern Europe, North America, and Western Eu- rope, which is the region with the highest incidence rate in the world (Ferlay et al., 2010) (Figure 13.3.1). Crude cause-specific mortality due to breast cancer in Georgia in 2006 (7.9 deaths from cancer per 100,000 women aged 15-44) was slightly higher than the Eu- ropean average, perhaps reflecting late detection and treatment. Recently, Georgia has been aggressively seeking to increase the screening of reproductive tract cancers. Through the new national screening program and un- der patronage of the First Lady of Georgia, early breast and cervical cancer detection has been promoted through free access to screening, by education of cli- nicians, and by increased public awareness. In 2006 the Georgian National Screening Center was opened in Tbilisi through collaboration between the MoLHSA, Tbilisi municipality, and UNFPA. While the Center ini- tially targeted women in Tbilisi, the success of the pro- gram prompted the government to scale it up to the national level. The Center was awarded the “Pearl of Wisdom” Award in 2009 at the European Parliament Cervical Cancer Prevention Summit Meeting in Brus- sels. The Center also promoted the formation of the Black Sea Countries Coalition on Breast and Cervical Cancer Prevention, with support from the UNFPA and the First Lady. Efforts to increase awareness of breast and cervical cancer and promote screening practices were also the focus of USAID–supported projects, starting with the Healthy Women in Georgia project. Through these efforts, several “Race for the Cure” awareness campaigns were organized in Tbilisi. The current project, implemented by JSI (SUSTAIN), cov- ers a broad range of social mobilization activities and breast cancer clinical training for health providers. Currently available practices for detecting breast cancer include breast self-examination (BSE), clini- cal breast examination (CBE), and mammography. Guidelines for the early detection of breast cancer in average-risk women consist of a combination of regular clinical breast examination and counseling to raise awareness of breast symptoms beginning at age 20, and annual mammography beginning at age 40 (American Cancer Society, 2005). BSE is a very sim- ple self-care procedure that can detect changes in the breast over time and can be performed by women in the privacy of their homes after minimal instruction. BSE is recommended as a supportive detection system to be used in conjunction with CBE and mammogra- phy. Women should be told about the benefits and limitations of BCE and the importance of prompt re- porting of any new breast symptoms to a health care professional. Women who choose to do BSE should receive instruction and have their technique reviewed on the occasion of a periodic health examination. Ap- propriate follow-up by a physician should be available for women who detect breast changes through self- examination. At that point, CBE and, when indicated, mammography should be conducted. The Georgia 2010 RHS explored the level of expe- rience with BSE and how often the exam was per- formed. Overall, 42% of sexually experienced women had ever performed BSE (Table 13.3.1) which is higher than in 2005 (29%). In terms of BCE frequency, 17% of sexually experienced women reported having one every month, 12% every 2-5 months, 12% every 6-12 months or less often, and 58% never. Levels of BSE us- age were lower among women in rural areas, younger women, the two poorest quintiles, and ethnic minor- ity women. Also, having ever conducted a BSE was correlated with having the experience of a routine gy- necological exam. This is likely because a gynecologi- cal exam is an important opportunity for a clinician to encourage and instruct a woman on how to perform a BSE. As mentioned above, BSE is not adequate on its own; consequently, women were also asked about the uti- Figure 13.2 50 40 30 20 10 0 Percent 1999 2005 Prevalence of Routine Gynecologic Visits during the Past Year by Residence among Sexually Experienced Women Aged 15-44 Years: 1999, 2005, and 2010 Total Urban Rural 30 20 25 33 22 28 26 18 20 2010 FINAL REPORT 223 lization of CBE and mammography. A CBE – a physical examination of the breast done by a health profession- al to detect abnormalities – can be part of a routine health examination. Table 13.3.2 shows that less than fifth (18%) of sexually experienced women had ever had a CBE, and that a disparity exists between urban and rural women (22% vs. 13%, respectively). The pro- portion of women who had ever had a CBE increased with age, educational attainment, and wealth, both for all women and for those with sexual experience. Among sexually experienced women, almost twice as many ethnic Georgian women as those of other ethnic backgrounds had a CBE in their lifetime (19% vs. 10%). Because breast cancer risk increases with age, mam- mography screening is primarily targeted to older women. Therefore women in the oldest age group surveyed (40-44) were more likely to report mammog- raphy screening compared to their younger counter- parts. In Tbilisi, where the Georgian cancer screening program was initially focused, the utilization of mam- mography was at least double that in other regions. Thirteen percent of sexually experienced women in Tbilisi had ever had mammography, whereas the pro- portion in all other regions ranged from 3% in Samt- skhe-Javakheti to a little over 6% in Mtskheta-Mtian- eti. Women who had never had a mammogram were asked the main reason why not. In Table 13.3.3 and Figure 13.3.2 responses were divided almost evenly into three categories: no doctor had ever recommend- ed it (33%), they had never heard of mammography (32%), and they did not think it was necessary (30%) Awareness of mammography was greater in Tbilisi, where only 22% of women had never heard of it. A fifth of women aged 35-44, a group who are in or soon will be in the target group for mammogram screen- ing in Georgia, still had never heard of this screening practice. 13.4 Cervical Cancer Screening and HPV Awareness Cervical cancer is the third most common cancer of women, with an estimated 530,000 new cases globally in 2008 (Ferlay et al., 2010). Both the age-adjusted in- cidence (9.4 new cases of cervical cancer per 100,000) and the age-adjusted mortality (4.7 deaths due to cer- vical cancer per 100,000) reported in Georgia for 2008 were higher than those in industrialized countries and other Western Asia Countries, but lower than those in Central and Eastern Europe (Figure 13.4.1). The Geor- gian study of the main causes of death among women of reproductive age found that cervical cancer was the fourth leading cause of death among these women in 2006 (Serbanescu et al., 2009). The Papanicolaou (Pap) smear is the primary method of screening for cervical cancer and while guidelines vary by country, being often dependent upon availa- ble recourses, most recommend that women who are sexually active should have a Pap smear test at least Figure 13.3.1 100 80 60 40 20 0 Percent Incidence Deaths Breast Cancer Incidence and Mortality, by Region, 2008 Rates per 100,000 women North America 77 15 90 18 45 17 33 14 39 20 Western Europe Central& Eastern Europe Western Asia Georgia Figure 13.3.2 Most Commonly Cited Reasons for Never Having Had a Mammogram Among Sexually Experienced Women Aged 15-44 3% 2% 22% 33% 30% Never Heard of Mammogram Doctor Never Recommended Did Not Think It Was Necessary Cost/Not Covered by Insurance Other REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 224 once every three to five years. In industrialized nations screenings are recommended as early as age18 but in resource-poor settings the core group that should be targeted is usually women aged 30-60 years. The age group targeted for cervical cancer screening by the Georgian screening program mentioned in the prior section is age 25-60 and the recommended frequency of the screening test is every three years. Survey reports are a useful way to estimate the ex- tent of cervical screening in the general population. All of the reproductive health surveys in Georgia have included a series of questions regarding Pap test his- tory to determine if the respondents had ever had a Pap smear test and, if so, when they had their most re- cent test. In the current survey, 12% of sexually experi- enced women aged 15-44 reported ever having had a Pap smear test (Table 13.4.1); that is very low, but it is a sizeable increase from the 4% reported in both 2005 and 1999 (Figure 13.4.2). Five percent have had a test in the past 12 months, and that is also an improve- ment over the last two surveys. The low prevalence of cervical cancer screening does not allow subgroup breakdowns to study the potential determinants of that preventive practice. However as shown for Pap tests in Table 13.4.2, the higher prevalence of tests in Tbilisi in the 25-34 and 35-44 age groups (15% and 22%, respectively) suggest that the targeted screening campaign there for reproductive cancers had a posi- tive impact. As it expands nationally cervical cancer screening should be more widely practiced in other regions as well. One of the major risk factors for cervical cancer is in- fection with human papilloma virus (HPV). The devel- opment of HPV vaccines in the last decade has pro- vided a safe and effective tool for the prevention of cervical cancer. For the first time, GERHS10 explored the level of awareness and use of the HPV vaccine in Georgia. Women were asked a series of questions about their awareness of HPV, their knowledge that a vaccine to prevent cervical cancer exists, and their interest (or lack of it) in getting the vaccine. Among all women aged 15-44 only 21% had ever heard of HPV infection, and only 18% had heard of the vaccine for it (Table 13.4.3). Once told about the vaccine’s effectiveness in preventing cervical cancer 29% expressed an interest in receiving it. Awareness of HPV infection was twice as high in Tbilisi (34%) as in most other regions. Awareness of the vaccine for it was also highest in Tbilisi. While awareness increased with age, interest in receiving the vaccine was inverse- ly correlated with age, perhaps because the vaccine is recommended for use in young girls, who are less likely to be sexually experienced or to have been in- fected. Both awareness and interest increased with education. Awareness of HPV and of the vaccine were Figure 13.4.1 20 15 10 5 0 Percent Incidence Deaths Cervical Cancer Incidence and Mortality, by Region, 2008 Rates per 100,000 women North America 6 2 7 2 15 6 5 2 9 5 Western Europe Central& Eastern Europe Western Asia Georgia Note: Rates are age-standardized, so they permit international comparisons regardless of varying age struc- tures. Source: Ferlay J, et al., Cancer Incidence and Mortality Worldwide: IARC Cancer Base No 10, 2010 Figure 13.4.2 20 15 10 5 0 Percent Ever had Screening Screening Within the Last Year Prevalence of Cervical Cancer Screening Tests Among Sexually Experienced Women Aged 15-44 Georgia 1999 4 1 4 2 12 5 Georgia 2005 Georgia 2010 Source: CDC and ORC/MACRO, 2003. FINAL REPORT 225 far lower among ethnic minorities (7%), pointing to an important area for improvement in outreach ef- forts. Once informed, many women in these groups expressed an interest in getting vaccinated (20%). 13.5 Tuberculosis Awareness and Exposure According to WHO, 1.7 million people died from TB in 2009, equal to 4,700 deaths a day. Of these 380,000 were women, and another 380,000 were people with HIV, (WHOb, 2010). In 2009 there were an estimated 9.4 million incident cases of TB globally (equivalent to 137 cases per 100,000 population). The deteriora- tion of health systems in the early 1990s, including TB control efforts, contributed to a major TB problem in Georgia specifically and elsewhere in the former So- viet Union. WHO estimates that in 2009, Georgia had an incidence rate of 107 cases per 100,000 popula- tion. Multidrug resistant TB (MDR-TB) is particularly problematic in Georgia, accounting for 10% of all new cases and 31% of retreatment cases. Georgia has been identified as one of the 27 high MDR-TB burden countries and has been included in the EXPAND-TB (expending Access to New Diagnostics for TB) project within the global STOP TB Partnership. After identify- ing TB as one of the nation’s greatest public health threats in the early 1990s, the Ministry of Labor, Health, and Social affairs established the National TB Control Program (NTCP) in 1995. In 1997, pilot sites for Directly Observed Therapy short-course (DOTS) implementation were created, and gradually the DOTS strategy was introduced countrywide. Since 2003, US- AID Georgia has supported the NTCP to improve the DOTS coverage; increase treatment success rates and reduce treatment default rates; strengthen clinical and laboratory services for TB patients; and promote linkages between HIV/AIDS and TB treatment efforts (USAID Georgia, 2009). Almost all women surveyed (95%) were aware of tu- berculosis (Table 13.5.1, left panel). Over two-thirds (67%) correctly indicated that it is transmitted through the air when coughing. Correct knowledge of trans- mission was higher among urban women and in- creased directly with the wealth quintile (SES) of the household (Figure 13.5). Women aged 15-19 (53%), those with less than complete secondary education (50%), and minority women (45%) were the least likely to know that TB is transmitted through cough- ing. Over half of respondents (57%) mentioned other ways of TB transmission. Almost one in eight women (12%) had no knowledge about how TB can spread. A substantial proportion of women had been exposed to TB either from a family member who has had TB (12%) (Table 13.5.1). Residents of Kvemo-Kartli (17%) and Kakheti (15%), women with the lowest educa- tion (17%), and minority women (23%) were the most likely to report they had been exposed to TB in their households. When asked their knowledge of specific symptoms of TB, most women knew of prolonged and severe coughing (71%). Fewer women were aware of fever (28%), blood in sputum (27%), weight loss (24%), or other items (Table 13.5.2). Knowledge of various symptoms was consistently lower in rural parts of the country than in urban areas. Knowledge generally in- creased with age and education. Despite the nearly universal awareness of TB, only three-quarters (75%) of women were aware that TB can be completely cured (Table 13.5.3). The women who were most frequently aware that TB is curable in- cluded those with technicum or university/postgradu- ate education (83% and 85% respectively), those aged 30 to 44 (83%), those who were employed (87%), and those residing in households with the wealthiest quin- tiles (85%). When asked the most appropriate treat- Figure 13.5 100 80 60 40 20 0 Percent Correct Knowledge of Tuberculosis Transmission by Residence and SES Total Urban Rural Lowest Second Middle Fourth Highest Residence SES 67 74 59 54 59 67 74 77 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 226 ment for TB-infected people the vast majority (78%) said they should be hospitalized, 13% said they should be hospitalized initially and then treated at home, and 1% said they should be treated entirely at home. These perceptions were roughly similar across demo- graphic groups but should be examined closely for specialized TB studies. 13.6 Cigarette Smoking Tobacco contains potent human carcinogens that have been shown to be related to many cancers in- cluding those of respiratory and digestive tracts, blad- der, cervix, and kidney. Worldwide approximately 5 million deaths are attributable to tobacco use; a num- ber expected to double by 2020 (WHO, 2003). Tobac- co smoking accounts for an estimated 22% of cancer deaths per year, including 70% of lung cancer deaths. Aside from cancer, smoking can also be linked to a variety of other health issues such as atherosclerosis, asthma, emphysema, pneumonia, and osteoporosis. Maternal smoking has been linked to low birth-weight babies, pre-term deliveries, miscarriages, sudden in- fant death syndrome, and infant respiratory problems (DiFranza and Lew, 1996). Several questions were posed to women to assess their cigarette-smoking status. Only a very small per- centage of women aged 15-44 were current tobacco smokers (6%) (Table 13.6.1). Five percent of them were daily smokers and 1% were occasional smokers. Not only did 94% of women indicate that they were not current smokers, 92% stated that they had never smoked. Overall, reports of ever, current, and past smoking were low with only 8% of women having smoked, 6% being current smokers and 2% being past smokers (Ta- ble 13.6.2). Ever-smoking was correlated with age up through age 34; however above that age patterns of smoking experience were quite similar (Figure 13.6). There was also a higher prevalence of smoking among women in urban areas. Almost a tenth (9%) of urban women reported being current smokers, and 13% of Tbilisi women in particular, compared to only 2% of women in rural areas. A full 98% of women in rural areas had never smoked at all. For individuals who do not use tobacco themselves, there are still the risks associated with second hand smoke (SHS). There is no safe level of exposure to SHS and it can still cause lung cancer in nonsmokers. It has also been associated with heart disease in adults and sudden infant death syndrome, ear infections, and asthma attacks in children (US DHHS, 2006; US DHHS, 2010). A recent study showed that worldwide, over 600,000 deaths each year are attributable to SHS, 165,000 of which are children (Oberg et al., 2011). It also found that Eastern Europe is one of the regions with the highest exposures to SHS, and the Georgia RHS 2010 confirms high numbers. Although the ma- jority of women surveyed did not smoke, one in two reported high levels of current (in the past 30 days) SHS both at home and at work. The level of SHS in the home was high for everyone, reported by 52% of women aged 15-44 and 50% of non-smokers (Table 13.6.3). Georgia has taken steps to combat second hand smoke, by developing and recently updating national tobacco control legislation, and by signing on to the WHO Framework Convention on Tobacco Control (FCTC) in 2006 (WHO, 2003). The WHO FCTC calls for the protection of all people from exposure to tobacco smoke and stresses the im- portance of demand reduction strategies as well as supply issues. Figure 13.6 15 10 5 0 Percent Lifetime, Current, and Past Smoking Prevalence by Age Group among Women Aged 15-44 15-19 Ever Smoked Past Smoker Current Smoker 2.6 2.2 0.4 7.3 4.7 2.6 8.4 6.4 2.0 10.3 7.0 3.3 9.8 6.9 2.9 9.5 6.3 3.2 20-24 25-29 30-34 35-39 40-44 FINAL REPORT 227 13.7 Alcohol Use As a result of gender differences in absorption and metabolism of alcohol, women experience higher concentrations of alcohol in the blood and become more impaired than men do after drinking equivalent amounts of alcohol, making them more vulnerable to alcohol’s long term health effects. Heavy drinking is associated with a number of chronic health conditions, including liver disease, cancer, car- dio-vascular disease, and neurological damage, as well as a variety of psychiatric problems. Binge drinking in particular has been most commonly associated with unintentional injuries, violence, alcohol poisoning, hy- pertension, myocardial infarction, sexually transmit- ted diseases, meningitis and poor control of diabetes (Naimi et al., 2003). Alcohol abuse among pregnant women has additional significance because of its po- tential harm to the fetus. No amount of alcohol is safe to drink during pregnancy, nor is there a safe period during pregnancy for alcohol consumption. Drinking during pregnancy can risk birth defects (fetal alcohol spectrum disorders), physical and mental develop- mental problems and even miscarriage, stillbirth, and premature delivery (Wilsnack et al., 1984; Kesmodel et al., 2002). The Georgia survey measured alcohol use by asking respondents about the frequency and quantity of their drinking in the past three months. Having at least one drink daily or almost every day was considered current drinking; consuming in excess of one drink per day, on average, was considered current frequent drinking, and the consumption of five or more drinks in a row at a given time was defined as episodic heavy drinking or “binge” drinking. Because data are based on self-reports, they might be subject to reporting bias, especially among pregnant respondents who may have been aware that alcohol use in pregnancy is discouraged. On average, 31% of women have ever drunk alcohol and 17% are current drinkers, but 2% are current fre- quent drinkers (Table 13.7). Eight percent of women reported binge drinking in the three months preced- ing the survey. As in the 2005 survey, drinking corre- lated somewhat with age, except for binge drinking (Figure 13.7). Of note is the relatively higher preva- lence of current, frequent, and binge drinking (22%, 6% and 14%, respectively) among women who were previously married. Binge drinking in particular was more common among urban women (9%), especially in Tbilisi (12%), and women in the wealthiest quintile (12%). Frequent and binge drinking were rarely re- ported by Azeri women (0% and 1%, respectively) sug- gesting that there may be protective factors against alcohol abuse in this population. 13.8 Prevalence of Selected Health Problems To explore selected health problems among women of reproductive age, all study participants were asked: “Has a doctor or other health care provider ever told you that you have (below listed) health problems?” The health problems listed in the questionnaire were: diabetes, anemia, high blood pressure, and heart dis- ease. The prevalence of pelvic inflammatory diseases (PID) was assessed by asking respondents an addition- al question, whether they “Had ever been treated for an infection of the fallopian tubes, uterus, or ovaries, also called pelvic infection?” The most commonly reported health problem among women of reproductive age was PID: 19% of all re- spondents, 29% of married women, and 32% of those aged 35-44 had been told by a doctor that they had PID. Few (7%) young woman aged 19-24 reported PID; it was rare among the somewhat overlapping group of never married women (Table 13.8). The second most common condition was high blood pressure: overall about 6% of respondents and 11% of older women aged 35-44 reported hypertension. Other health problems included anemia, heart dis- Figure 13.7 50 40 30 20 10 0 Percent Current Drinking Percentages by Age Group Among Women Aged 15-44 15-24 29 14 1 9 29 16 1 9 34 20 3 7 25-34 35-44 Ever Drank Current Frequent Drinker Current Drinker Binger REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 228 ease, and diabetes: about 4% of study participants had been diagnosed with anemia, 3% reported heart disease, and 1% had been told that they had diabetes. In general, survey data are imperfect regarding these selected health problems. No lab testing was done; all data are based on self-reports, and many respond- ents did not know or could not specify their problems. Therefore the true rates of the diseases are much higher than reported. In addition, the various region- al distributions of the health conditions are impacted by the availability of medical facilities in the regions. Furthermore, the questionnaire collected information about the lifetime occurrence of diseases and did not estimate new cases. For all these reasons, the study could not provide fully accurate data on women’s health problems, and the results should be consid- ered as minimum estimates of the true prevalence of these conditions among women of childbearing age. Table 13.1.1 Percentage of Women Aged 15–44 Who Had a Usual Place of Care and Percentage Distribution by Usual Place for Health Care by Selected Characteristics Reproductive Health Survey: Georgia, 2010 % No. of Cases Regional/ City Hospital % Policlinic/ Women's Consultation Clinic % Primary Health Care/ Family Medicine Center % Other % None % Total No. of Cases Total 79.4 6,292 37.9 25.6 14.4 1.4 20.6 100.0 6,292 Characteristic Had a Usual Place of Care Usual Place for Health Care Residence Urban 80.7 2,975 30.5 32.9 16.2 1.1 19.3 100.0 2,975 Rural 77.9 3,317 46.3 17.4 12.4 1.7 22.1 100.0 3,317 Region Kakheti 79.7 498 39.4 20.9 17.1 2.4 20.3 100.0 498 Tbilisi 78.0 1,426 20.2 34.8 21.6 1.3 22.0 100.0 1,426 Shida Kartli 86.8 392 60.4 18.7 7.7 0.0 13.2 100.0 392 Kvemo Kartli 73.7 546 40.0 23.1 10.1 0.4 26.3 100.0 546 Samtskhe–Javakheti 78.3 481 49.4 17.9 10.4 0.6 21.7 100.0 481 Adjara 75.8 419 37.5 29.3 8.5 0.5 24.2 100.0 419 Guria 74.4 401 40.0 26.4 7.8 0.2 25.6 100.0 401 Samegrelo 89.2 477 60.0 23.9 3.9 1.5 10.8 100.0 477 Imereti 80.2 805 40.2 19.3 17.8 2.9 19.8 100.0 805 Mtskheta–Mtianeti 78.9 393 34.0 23.4 20.5 1.0 21.1 100.0 393 Racha–Svaneti 84.7 454 62.9 9.4 6.9 5.5 15.3 100.0 454 Age Group 15 19 71 0 861 31 0 26 4 12 6 1 0 29 0 100 0 86115–19 71.0 861 31.0 26.4 12.6 1.0 29.0 100.0 861 20–24 76.0 1,099 35.2 26.1 13.2 1.5 24.0 100.0 1,099 25–29 81.5 1,191 40.1 25.6 14.5 1.2 18.5 100.0 1,191 30–34 82.4 1,168 42.0 25.3 13.6 1.4 17.6 100.0 1,168 35–39 85.0 1,051 40.1 25.9 17.1 1.8 15.0 100.0 1,051 40–44 82.2 922 40.7 24.0 16.2 1.2 17.8 100.0 922 Number of Living Children 0 75.0 2,276 33.8 26.3 13.6 1.2 25.0 100.0 2,276, , 1 82.6 1,286 37.5 27.3 16.3 1.5 17.4 100.0 1,286 2 82.7 2,069 42.2 25.2 13.9 1.4 17.3 100.0 2,069 3 or more 81.4 661 42.9 21.3 15.6 1.5 18.6 100.0 661 Education Level Secondary incomplete or less 73.1 1,330 37.4 23.7 11.2 0.9 26.9 100.0 1,330 Secondary complete 77.6 1,568 40.1 24.9 11.4 1.2 22.4 100.0 1,568 Technicum 82.3 903 45.3 24.8 10.8 1.4 17.7 100.0 903 University/postgraduate 83.1 2,491 34.4 27.5 19.4 1.8 16.9 100.0 2,491 Wealth Quintile Lowest 73.7 1,093 47.8 17.2 7.3 1.5 26.3 100.0 1,093 Second 78.9 1,385 46.6 18.4 12.2 1.7 21.1 100.0 1,385 Middle 80.7 1,413 44.2 22.0 13.0 1.5 19.3 100.0 1,413 Fourth 79.5 1,037 31.1 32.8 14.6 0.9 20.5 100.0 1,037 Highest 81.7 1,364 25.5 33.8 21.2 1.3 18.3 100.0 1,364 Employment Working 82 5 1 410 36 1 25 2 19 1 2 1 17 5 100 0 1 410Working 82.5 1,410 36.1 25.2 19.1 2.1 17.5 100.0 1,410 Not working 78.5 4,882 38.4 25.8 13.2 1.2 21.5 100.0 4,882 Ethnicity Georgian 80.8 5,488 37.7 26.5 15.1 1.5 19.2 100.0 5,488 Other 69.8 804 39.3 20.1 9.7 0.7 30.2 100.0 804 Has Health Insurance Yes 85.1 1,548 35.3 23.2 24.2 2.4 14.9 100.0 1,548 No 77.7 4,744 38.7 26.3 11.7 1.1 22.3 100.0 4,744 FINAL REPORT 229 Table 13.1.2 Receipt of Any Medical Care in the Last 12 Months and Type of Care by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010p y g , % No. of Cases Preventive Care Acute Care Care for Chronic Conditions No. of Cases Total 36.6 6,292 41.1 50.7 20.0 2,353 Residence Urban 38.7 2,975 42.6 49.4 20.1 1,172 R l 34 3 3 317 39 1 52 5 20 0 1 181 Any Medical Care in the Last 12 Months Characteristic Type of Medical Care Rural 34.3 3,317 39.1 52.5 20.0 1,181 Region Kakheti 39.2 498 46.8 46.4 27.0 205 Tbilisi 40.7 1,426 43.1 51.6 18.0 580 Shida Kartli 34.9 392 36.7 56.5 19.8 142 Kvemo Kartli 32.7 546 43.7 48.0 20.1 187 Samtskhe–Javakheti 30.9 481 34.7 58.3 13.6 159 Adjara 25.9 419 31.5 47.9 26.7 119 G i 33 0 401 57 0 50 3 7 9 139Guria 33.0 401 57.0 50.3 7.9 139 Samegrelo 35.0 477 41.3 51.0 16.8 174 Imereti 43.0 805 39.0 50.9 20.9 352 Mtskheta–Mtianeti 29.7 393 39.7 44.2 25.6 124 Racha–Svaneti 38.9 454 30.6 53.4 24.7 172 Age Group 15–19 30.6 861 27.1 61.3 16.3 273 20–24 36.6 1,099 47.8 45.7 14.3 428 25–29 40.1 1,191 45.8 43.7 18.5 475 30–34 38.6 1,168 44.7 51.3 17.4 454 35–39 36.0 1,051 42.4 51.1 25.5 379 40–44 38.6 922 35.5 54.0 30.0 344 Number of Living Children 0 32.6 2,276 32.9 56.0 19.5 776 1 42.1 1,286 54.5 39.8 16.2 541, 2 39.9 2,069 40.6 53.4 21.2 807 3 or more 33.1 661 44.0 46.6 27.1 229 Education Level Secondary incomplete or less 30.3 1,330 32.9 55.0 19.7 427 Secondary complete 35.5 1,568 43.0 46.8 21.6 563 Technicum 38.8 903 34.6 57.8 23.7 348 University/postgraduate 40.2 2,491 45.7 48.8 18.1 1,015 Wealth Quintile Lowest 31.7 1,093 37.6 54.7 23.3 367 Second 34.0 1,385 42.0 49.5 18.5 483 Middle 37.7 1,413 37.4 52.1 20.1 547 Fourth 39.4 1,037 42.7 44.6 23.9 411 Highest 38.5 1,364 44.0 53.1 16.6 545 Employment Working 40.7 1,410 45.0 46.7 18.3 572g Not working 35.5 4,882 39.9 52.0 20.5 1,781 Ethnicity Georgian 37.4 5,488 41.5 50.4 19.9 2,092 Other 31.2 804 37.8 53.9 20.9 261 Has Health Insurance Yes 48.7 1,548 42.0 52.2 19.6 736 No 33.2 4,744 40.7 50.1 20.2 1,617 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 230 Table 13.1.3 Delayed Medical Care and Main Reason for Delay in the Last 12 Months by Selected Characteristics among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010p y g , % No. of Cases Cost Related Other Reasons Does not Remember Total 25.2 6,292 82.0 17.8 0.2 100.0 1,672 Residence Urban 22 3 2 975 75 5 24 2 0 4 100 0 682 Characteristic Delayed Medical Care in the Last 12 Months Total No. of Cases Main Reason to Delay Care Urban 22.3 2,975 75.5 24.2 0.4 100.0 682 Rural 28.6 3,317 87.7 12.2 0.1 100.0 990 Region Kakheti 21.2 498 84.3 15.7 0.0 100.0 109 Tbilisi 23.4 1,426 67.6 31.7 0.7 100.0 339 Shida Kartli 29.6 392 94.7 5.3 0.0 100.0 118 Kvemo Kartli 30.1 546 85.3 14.7 0.0 100.0 168 Samtskhe–Javakheti 25.5 481 89.0 10.4 0.6 100.0 130 Adjara 22 6 419 89 0 11 0 0 0 100 0 93Adjara 22.6 419 89.0 11.0 0.0 100.0 93 Guria 24.8 401 87.1 12.9 0.0 100.0 100 Samegrelo 26.9 477 87.5 12.5 0.0 100.0 135 Imereti 24.0 805 84.9 15.1 0.0 100.0 193 Mtskheta–Mtianeti 35.4 393 82.3 17.2 0.5 100.0 140 Racha–Svaneti 31.4 454 79.1 20.9 0.0 100.0 147 Age Group 15–19 10.1 861 80.6 19.4 0.0 100.0 88 20–24 16 8 1 099 77 1 22 9 0 0 100 0 18620–24 16.8 1,099 77.1 22.9 0.0 100.0 186 25–29 22.0 1,191 80.0 19.8 0.2 100.0 272 30–34 32.1 1,168 82.5 17.2 0.3 100.0 383 35–39 33.2 1,051 83.3 16.0 0.7 100.0 352 40–44 42.3 922 84.5 15.5 0.0 100.0 391 Number of Living Children 0 16.4 2,276 76.9 23.0 0.1 100.0 391 1 23.8 1,286 81.1 18.8 0.1 100.0 3131 23.8 1,286 81.1 18.8 0.1 100.0 313 2 33.2 2,069 84.0 15.6 0.5 100.0 701 3 or more 40.8 661 86.6 13.4 . 100.0 267 Education Level Secondary incomplete or less 25.4 1,330 91.1 8.9 0.0 100.0 351 Secondary complete 26.4 1,568 88.1 11.8 0.1 100.0 437 Technicum 31.7 903 86.9 13.1 0.0 100.0 294 University/postgraduate 22.2 2,491 69.1 30.3 0.6 100.0 590University/postgraduate 22.2 2,491 69.1 30.3 0.6 100.0 590 Wealth Quintile Lowest 33.0 1,093 90.1 9.9 0.0 100.0 373 Second 27.7 1,385 88.6 11.4 0.0 100.0 400 Middle 26.6 1,413 86.9 12.9 0.1 100.0 382 Fourth 22.4 1,037 80.4 19.2 0.4 100.0 237 Highest 19.9 1,364 63.2 36.1 0.7 100.0 280 Employment Working 26.3 1,410 65.2 34.3 0.5 100.0 386Working 26.3 1,410 65.2 34.3 0.5 100.0 386 Not working 24.9 4,882 86.8 13.1 0.1 100.0 1,286 Ethnicity Georgian 25.1 5,488 80.6 19.2 0.2 100.0 1,462 Other 25.8 804 91.0 8.7 0.2 100.0 210 Has Health Insurance Yes 29.0 1,548 69.3 30.4 0.2 100.0 462 No 24.2 4,744 86.3 13.5 0.2 100.0 1,210 FINAL REPORT 231 Table 13.1.4 Percentage of Women Aged 15–44 with Health Insurance Coverage at the Time of the Interview and Main Sources of Health Insurance by Selected Characteristics Reproductive Health Survey: Georgia, 2010 % No. of Cases Government– funded Private (Through Employer) Private (Self–funded) Total 22.1 6,292 49.1 32.6 18.3 100.0 1,542 Residence p y g , Characteristic Has Health Insurance Source of Health Insurance Total No. of Cases * Urban 21.4 2,975 28.8 42.1 29.0 100.0 659 Rural 23.0 3,317 70.4 22.7 6.9 100.0 883 Region Kakheti 20.1 498 69.3 19.7 11.0 100.0 110 Tbilisi 23.3 1,426 19.7 45.8 34.5 100.0 333 Shida Kartli 24.9 392 71.4 19.8 8.7 100.0 101 Kvemo Kartli 14.1 546 49.0 22.9 28.1 100.0 77 Samtskhe–Javakheti 19.1 481 34.1 61.8 4.1 100.0 98Samtskhe–Javakheti 19.1 481 34.1 61.8 4.1 100.0 98 Adjara 25.4 419 55.9 26.6 17.5 100.0 105 Guria 26.6 401 75.2 18.0 6.8 100.0 109 Samegrelo 21.2 477 66.7 26.2 7.1 100.0 98 Imereti 21.1 805 56.0 34.4 9.6 100.0 181 Mtskheta–Mtianeti 33.7 393 74.6 16.9 8.5 100.0 132 Racha–Svaneti 42.1 454 81.4 15.7 3.0 100.0 198 Age Group 15 19 16 8 861 73 8 13 1 13 1 100 0 15015–19 16.8 861 73.8 13.1 13.1 100.0 150 20–24 18.2 1,099 51.1 30.1 18.9 100.0 212 25–29 23.2 1,191 47.3 34.1 18.6 100.0 307 30–34 22.5 1,168 45.9 36.1 18.0 100.0 298 35–39 24.5 1,051 43.7 37.1 19.3 100.0 298 40–44 29.7 922 39.5 40.0 20.4 100.0 277 Number of Living Children 0 18 8 2 276 51 6 27 7 20 7 100 0 4720 18.8 2,276 51.6 27.7 20.7 100.0 472 1 23.4 1,286 40.4 37.9 21.7 100.0 316 2 24.0 2,069 47.3 35.9 16.8 100.0 547 3 or more 27.9 661 60.0 29.8 10.3 100.0 207 Education Level Secondary incomplete or less 19.3 1,330 81.9 9.5 8.6 100.0 294 Secondary complete 18.2 1,568 80.6 10.4 9.0 100.0 333 Technicum 19 8 903 56 3 29 2 14 5 100 0 204Technicum 19.8 903 56.3 29.2 14.5 100.0 204 University/postgraduate 27.0 2,491 20.5 52.4 27.1 100.0 711 Wealth Quintile Lowest 27.7 1,093 91.0 5.6 3.4 100.0 345 Second 22.7 1,385 67.2 25.5 7.2 100.0 356 Middle 20.0 1,413 54.0 34.5 11.5 100.0 321 Fourth 16.7 1,037 36.7 37.4 25.9 100.0 186 Highest 24.3 1,364 12.0 51.5 36.6 100.0 334 E lEmployment Working 38.6 1,410 13.4 59.2 27.4 100.0 571 Not working 17.7 4,882 70.3 16.9 12.8 100.0 971 Ethnicity Georgian 23.9 5,488 48.5 32.8 18.7 100.0 1,442 Other 10.6 804 58.0 29.7 12.3 100.0 100 * Excludes 6 women who did not know the type of health insurance coverage. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 232 Table 13.2 Time of Last Routine Gynecologic Exam by Selected Characteristics Among Women Aged 15–44 Who Had Ever Had Sexual Intercourse Reproductive Health Survey: Georgia, 2010p y g , During the Past 12 Months Within 1–3 Years More than 3 Years Ago Never Had Total 24.6 26.1 20.1 29.3 100.0 4,473 Residence Urban 28.2 27.6 19.8 24.5 100.0 2,039 Characteristic Timing of Last Routine Gynecologic Exam Total No. of Cases* Rural 20.8 24.5 20.4 34.3 100.0 2,434 Region Kakheti 19.8 29.6 20.7 29.8 100.0 377 Tbilisi 30.8 28.3 19.6 21.4 100.0 941 Shida Kartli 23.1 24.6 26.0 26.3 100.0 285 Kvemo Kartli 23.7 21.9 16.8 37.7 100.0 416 Samtskhe–Javakheti 21.8 19.9 18.4 40.0 100.0 349 Adjara 20.7 30.4 16.6 32.2 100.0 314j Guria 16.9 24.4 19.0 39.8 100.0 288 Samegrelo 21.9 24.9 22.4 30.9 100.0 325 Imereti 26.8 24.4 22.1 26.8 100.0 584 Mtskheta–Mtianeti 15.6 26.7 20.0 37.8 100.0 290 Racha–Svaneti 20.6 22.1 22.3 35.0 100.0 304 Age Group 15–24 31.8 19.6 3.2 45.3 100.0 770 25–29 28.5 27.4 10.5 33.6 100.0 90825 29 28.5 27.4 10.5 33.6 100.0 908 30–34 25.5 27.1 18.5 29.0 100.0 1,027 35–39 20.7 29.4 28.4 21.5 100.0 941 40–44 17.2 26.0 37.5 19.3 100.0 827 Number of Living Children 0 38.3 13.2 9.9 38.6 100.0 477 1 26.0 26.1 15.7 32.1 100.0 1,283 2 22 9 28 4 22 5 26 2 100 0 2 0572 22.9 28.4 22.5 26.2 100.0 2,057 3 or more 17.1 28.1 28.2 26.6 100.0 656 Education Level Secondary incomplete or less 18.3 25.3 19.6 36.9 100.0 794 Secondary complete 22.6 23.2 19.3 34.9 100.0 1,192 Technicum 24.9 26.3 23.3 25.4 100.0 738 University/postgraduate 28.5 28.2 19.6 23.8 100.0 1,749 Wealth QuintileWealth Quintile Lowest 17.6 24.2 19.7 38.5 100.0 786 Second 21.4 24.1 21.1 33.4 100.0 1,025 Middle 23.5 24.0 20.7 31.8 100.0 1,013 Fourth 28.4 27.7 18.4 25.5 100.0 706 Highest 29.6 29.4 20.1 20.8 100.0 943 Ethnicity Georgian 24.9 26.2 21.1 27.8 100.0 3,847 Oth 22 5 25 3 14 2 38 0 100 0 626Other 22.5 25.3 14.2 38.0 100.0 626 Current Use of Contraception Modern 25.3 31.5 20.4 22.8 100.0 1,429 Traditional 20.0 26.9 21.2 31.9 100.0 797 No method 25.6 22.4 19.5 32.4 100.0 2,247 * Excludes 20 women who did not remember when they had the last routine gynecologic examination. FINAL REPORT 233 Table 13.3.1 Frequency of Breast Self–Examination (BSE) by Selected Characteristics Among Women Aged 15–44 Who Had Ever Had Sexual Intercourse Reproductive Health Survey: Georgia, 2010 Every Month Every 2–5 Months Every 6–12 Months or Less Never Had Total 17.1 12.4 12.4 58.1 100.0 4,493 Residence Urban 19.9 14.1 14.4 51.6 100.0 2,048 Characteristic Frequency of BSE Total No. of Cases Rural 14.3 10.6 10.3 64.9 100.0 2,445 Region Kakheti 17.9 13.8 12.9 55.4 100.0 380 Tbilisi 22.8 13.4 14.8 49.0 100.0 943 Shida Kartli 15.1 14.8 10.9 59.2 100.0 285 Kvemo Kartli 13.4 8.4 12.0 66.1 100.0 420 Samtskhe–Javakheti 7.4 5.7 11.7 75.2 100.0 350 Adjara 9.6 11.7 11.7 67.0 100.0 317 Guria 15.6 10.2 8.1 66.2 100.0 290Guria 15.6 10.2 8.1 66.2 100.0 290 Samegrelo 15.8 15.3 9.3 59.7 100.0 326 Imereti 20.4 13.3 11.8 54.5 100.0 586 Mtskheta–Mtianeti 18.8 11.9 16.0 53.3 100.0 292 Racha–Svaneti 11.5 14.3 10.3 63.9 100.0 304 Age Group 15–19 10.1 2.2 3.5 84.2 100.0 130 20–24 9.4 8.9 8.7 73.0 100.0 642 25–29 12.9 11.3 10.7 65.1 100.0 910 30–34 17.7 10.8 13.0 58.5 100.0 1,036 35–39 20.0 15.9 15.7 48.4 100.0 946 40–44 24.4 15.5 14.0 46.1 100.0 829 Number of Living Children 0 12.5 7.9 6.3 73.3 100.0 477 1 17.3 13.0 11.7 58.1 100.0 1,286 2 18.1 13.1 13.8 55.1 100.0 2,069 3 or more 17.2 12.4 14.1 56.3 100.0 661 Education LevelEducation Level Secondary incomplete or less 8.5 7.5 7.6 76.4 100.0 802 Secondary complete 13.4 11.7 10.9 63.9 100.0 1,196 Technicum 19.9 13.8 15.4 50.9 100.0 740 University/postgraduate 22.3 14.4 14.4 49.0 100.0 1,755 Wealth Quintile Lowest 12.5 9.6 9.6 68.3 100.0 788 Second 11.9 10.9 9.9 67.3 100.0 1,032 Middle 18.6 11.8 13.4 56.2 100.0 1,018 Fourth 17.7 11.9 12.4 58.0 100.0 710 Highest 22.5 16.1 15.3 46.1 100.0 945 Employment Working 24.8 17.4 14.6 43.2 100.0 1,013 Not working 14.9 10.9 11.8 62.4 100.0 3,480 Ethnicity Georgian 18.8 13.3 13.0 55.0 100.0 3,859 Other 7.3 7.0 9.1 76.6 100.0 634 Current Use of ContraceptionCurrent Use of Contraception Modern 19.3 14.7 14.8 51.3 100.0 1,436 Traditional 18.9 12.8 10.2 58.2 100.0 798 No method 15.2 10.8 11.7 62.4 100.0 2,259 Ever Had a Routine Gynecologic Exam Yes 19.5 14.2 13.8 52.5 100.0 3,099 No 11.3 8.0 9.1 71.6 100.0 1,394 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 234 Table 13.3.2 Prevalence of BSE, CBE and Mammography Screening by Selected Characteristics Among All Women and Sexually Experienced Women Aged 15–44 Reproductive Health Survey: Georgia, 2010Reproductive Health Survey: Georgia, 2010 All Women SexuallyExperienced All Women Sexually Experienced All Women Sexually Experienced All Women Sexually Experienced Total 32.1 41.9 13.1 17.7 4.9 6.8 6,292 4,493 Residence Number of Cases Characteristic Ever Had BSE Ever Had CBE Ever Had a Mammogram Residence Urban 36.2 48.4 15.8 21.9 6.9 9.7 2,975 2,048 Rural 27.5 35.1 10.1 13.4 2.8 3.8 3,317 2,445 Region Kakheti 35.0 44.6 13.4 18.3 4.1 5.9 498 380 Tbilisi 37.0 51.0 19.0 26.7 8.8 12.6 1,426 943 Shida Kartli 31.8 40.8 9.9 13.9 3.2 4.7 392 285 Kvemo Kartli 27.3 33.9 11.3 14.4 4.6 6.0 546 420 Samtskhe–Javakheti 17.2 24.8 6.5 10.0 2.2 3.3 481 350 Adjara 25.0 33.0 9.4 13.5 2.8 4.1 419 317 Guria 29.0 33.8 8.4 11.4 3.2 4.2 401 290 Samegrelo 29.9 40.3 8.1 10.1 2.7 3.8 477 326 Imereti 36.4 45.5 13.6 17.9 3.6 4.8 805 586 Mtskheta–Mtianeti 34.4 46.7 12.4 16.9 4.8 6.4 393 292 Racha–Svaneti 29.3 36.1 10.8 14.6 2.7 4.0 454 304 Age Group 15–19 5.4 15.8 3.0 7.2 0.4 0.0 861 130 20 24 19 4 27 0 7 6 11 2 1 7 2 6 1 099 64220–24 19.4 27.0 7.6 11.2 1.7 2.6 1,099 642 25–29 31.6 34.9 10.5 12.7 3.3 3.8 1,191 910 30–34 40.2 41.5 16.2 17.2 6.5 6.9 1,168 1,036 35–39 51.0 51.6 22.3 23.3 9.3 9.4 1,051 946 40–44 52.6 53.9 22.4 23.7 10.2 11.0 922 829 Number of Living Children 0 15.6 26.7 5.8 13.4 1.8 4.3 2,276 477 1 41.9 41.9 18.9 18.9 7.1 7.1 1,286 1,286 2 44 9 44 9 18 8 18 8 8 1 8 1 2 069 2 0692 44.9 44.9 18.8 18.8 8.1 8.1 2,069 2,069 3 or more 43.7 43.7 15.3 15.3 4.2 4.2 661 661 Education Level Secondary incomplete or less 14.2 23.6 5.7 8.7 1.9 3.2 1,330 802 Secondary complete 28.0 36.1 9.1 11.9 2.7 3.7 1,568 1,196 Technicum 41.8 49.1 17.4 20.6 6.5 7.9 903 740 University/postgraduate 41.7 51.0 18.4 24.4 7.5 10.0 2,491 1,755 Wealth Quintile Lowest 24 5 31 7 7 8 10 5 1 9 2 6 1 093 788Lowest 24.5 31.7 7.8 10.5 1.9 2.6 1,093 788 Second 25.5 32.7 9.4 12.1 3.1 4.3 1,385 1,032 Middle 33.5 43.8 11.6 15.9 3.0 4.4 1,413 1,018 Fourth 31.0 42.0 12.6 18.0 4.7 6.6 1,037 710 Highest 40.9 53.9 20.6 28.1 9.8 13.6 1,364 945 Ethnicity Georgian 34.2 45.0 14.0 19.1 5.4 7.5 5,488 3,859 Other 18.1 23.4 7.3 9.8 2.0 2.7 804 634 Current Use of ContraceptionCurrent Use of Contraception Modern 48.7 48.7 20.0 20.0 8.3 8.3 1,436 1,436 Traditional 41.8 41.8 14.3 14.3 6.2 6.2 798 798 No method 25.4 37.6 10.8 17.4 3.7 6.1 4,058 2,259 Ever Had a Routine Gynecologic Exam Yes 45.9 47.5 21.7 22.0 8.4 8.6 3,322 3,099 No 18.0 28.4 4.3 7.4 1.4 2.3 2,970 1,394 FINAL REPORT 235 Table 13.3.3 Most Commonly Cited Reasons for Never Having Had a Mammography by Selected Characteristics Among Women Aged 15–44 Who Had Never Had a Mammography Reproductive Health Survey: Georgia, 2010Reproductive Health Survey: Georgia, 2010 Doctor Never Recommended it Never Heard of Such Exam Did Not Think it Was Necessary/ Too Young Cost/ No Insurance/ Not Covered by Insurance Other* Total No. of Cases Total 33.4 31.7 29.8 3.0 2.1 100.0 5,984 Characteristic Main Reason for Never Having Had a Mammography Residence Urban 35.0 24.6 35.8 2.9 1.8 100.0 2,768 Rural 31.6 39.5 23.4 3.2 2.4 100.0 3,216 Region Kakheti 37.6 38.3 20.5 0.8 2.8 100.0 475 Tbilisi 34.5 21.9 39.0 2.2 2.4 100.0 1,300 Shida Kartli 33.0 36.7 25.1 4.1 1.2 100.0 381 Kvemo Kartli 31 9 35 9 25 6 3 7 2 8 100 0 519Kvemo Kartli 31.9 35.9 25.6 3.7 2.8 100.0 519 Samtskhe–Javakheti 18.7 56.3 24.1 0.5 0.3 100.0 470 Adjara 30.5 29.6 29.3 9.3 1.3 100.0 404 Guria 23.6 26.9 39.0 6.2 4.3 100.0 389 Samegrelo 30.1 45.9 22.1 1.0 0.9 100.0 462 Imereti 41.4 25.8 29.1 1.6 2.1 100.0 772 Mtskheta–Mtianeti 28.7 24.8 36.3 5.6 4.6 100.0 372 Racha–Svaneti 33.6 44.2 19.7 1.3 1.3 100.0 440 Age GroupAge Group 15–24 19.4 45.8 33.1 0.6 1.1 100.0 1,938 25–34 39.0 25.1 31.4 2.4 2.1 100.0 2,256 35–44 45.6 20.5 23.6 6.9 3.4 100.0 1,790 Number of Living Children 0 19.1 42.5 36.4 0.8 1.2 100.0 2,229 1 43.6 22.7 28.0 3.7 2.0 100.0 1,203 2 45 0 22 8 24 7 4 7 2 7 100 0 1 9192 45.0 22.8 24.7 4.7 2.7 100.0 1,919 3 or more 41.5 28.1 19.9 6.4 4.1 100.0 633 Education Level Secondary incomplete or less 20.4 51.5 23.9 2.5 1.6 100.0 1,303 Secondary complete 31.0 36.3 26.8 4.1 1.8 100.0 1,525 Technicum 39.6 21.8 31.5 5.5 1.6 100.0 847 University/postgraduate 40.7 20.0 34.9 1.7 2.7 100.0 2,309 Wealth QuintileWealth Quintile Lowest 28.5 45.8 20.0 3.4 2.3 100.0 1,072 Second 33.2 38.3 24.6 2.3 1.6 100.0 1,342 Middle 32.2 35.9 25.2 4.4 2.3 100.0 1,360 Fourth 35.4 25.5 34.8 2.5 1.8 100.0 983 Highest 36.0 18.7 40.3 2.5 2.4 100.0 1,227 Ethnicity Georgian 34.8 28.5 31.5 3.1 2.1 100.0 5,197 Other 24 1 52 2 19 3 2 3 2 2 100 0 787Other 24.1 52.2 19.3 2.3 2.2 100.0 787 Current Use of Contraception Modern 48.1 18.0 27.2 3.9 2.9 100.0 1,323 Traditional 40.0 26.8 27.6 3.7 1.9 100.0 752 No method 28.0 36.5 30.9 2.6 1.9 100.0 3,909 * Includes negligence, not knowing where the test is offered and fear of results. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 236 Table 13.4.1 History of Cervical Cancer Screening by Selected Characteristics Among Women Aged 15–44 Who Have Ever Had Sexual Intercourse Reproductive Health Survey: Georgia, 2010Reproductive Health Survey: Georgia, 2010 During the Past 12 Months Within 1–3 Years More than 3 Years Ago Never Had Total No. of Cases* Total 5.0 4.0 3.1 87.8 100.0 4,491 Residence U b 7 1 5 1 3 1 84 8 100 0 2 047 Characteristic Timing of Last Cervical Cancer Screening Urban 7.1 5.1 3.1 84.8 100.0 2,047 Rural 2.9 3.0 3.2 91.0 100.0 2,444 Region Kakheti 3.9 3.4 3.6 89.1 100.0 379 Tbilisi 10.0 7.0 3.3 79.7 100.0 942 Shida Kartli 3.0 1.5 4.4 91.1 100.0 285 Kvemo Kartli 3.2 3.4 3.0 90.4 100.0 420 Samtskhe–Javakheti 1.9 1.4 2.6 94.0 100.0 350 Adjara 4.3 4.6 2.8 88.3 100.0 317Adjara 4.3 4.6 2.8 88.3 100.0 317 Guria 4.8 5.4 4.5 85.3 100.0 290 Samegrelo 1.6 0.8 0.0 97.5 100.0 326 Imereti 3.7 3.4 4.2 88.7 100.0 586 Mtskheta–Mtianeti 4.4 2.5 1.1 92.0 100.0 292 Racha–Svaneti 2.3 3.7 2.9 91.1 100.0 304 Age Group 15–24 6.5 3.1 0.8 89.5 100.0 772 25–29 4.7 4.4 2.9 88.1 100.0 910 30 34 3 9 3 3 2 89 4 100 0 1 0330–34 3.9 3.5 3.2 89.4 100.0 1,035 35–39 5.4 4.1 4.2 86.2 100.0 946 40–44 4.8 5.0 4.2 86.0 100.0 828 Number of Living Children 0 6.5 3.3 1.9 88.2 100.0 477 1 6.0 4.3 2.6 87.1 100.0 1,285 2 4.8 4.1 3.5 87.6 100.0 2,069 3 or more 2.9 3.6 3.8 89.7 100.0 660 Education LevelEducation Level Secondary incomplete or less 2.0 1.3 1.7 95.0 100.0 802 Secondary complete 3.6 2.4 2.6 91.4 100.0 1,196 Technicum 5.6 4.9 3.5 86.0 100.0 739 University/postgraduate 7.1 6.0 4.0 83.0 100.0 1,754 Wealth Quintile Lowest 1.2 1.7 2.8 94.4 100.0 788 Second 3.7 2.8 3.8 89.6 100.0 1,032 Middle 3.0 3.4 2.4 91.2 100.0 1,017, Fourth 5.4 4.9 2.1 87.6 100.0 710 Highest 10.0 6.3 4.1 79.6 100.0 944 Ethnicity Georgian 5.6 4.1 3.5 86.8 100.0 3,857 Other 1.9 3.5 0.8 93.9 100.0 634 Current Use of Contraception Modern 5.0 4.1 3.3 87.5 100.0 1,436 Traditional 3.4 3.9 2.8 89.9 100.0 798 No method 5 6 4 0 3 1 87 4 100 0 2 257No method 5.6 4.0 3.1 87.4 100.0 2,257 Ever Had a Routine Gynecologic Exam Yes 6.3 4.9 3.6 85.2 100.0 3,097 No 1.9 2.0 1.9 94.1 100.0 1,394 * Excludes 2 women who did not remember if they had cervical cancer screening. FINAL REPORT 237 Table 13.4.2 Receipt of Cervical Cancer Screening in the Last 3 Years by Selected Characteristics and Age among Women Aged 15–44 Who Have Ever Had Sexual Intercourse 15–44 Who Have Ever Had Sexual Intercourse Reproductive Health Survey: Georgia, 2010 15–24 25–34 35–44 Total 9.6 8.1 9.7 4,491 Characteristic Had Cervical Cancer Screening in the Last 3 Years No. of Cases* Residence Urban 10.4 11.0 14.0 2,047 Rural 8.8 5.2 5.1 2,444 Region Kakheti 7.7 5.7 8.4 379 Tbilisi 11.1 14.8 21.6 942 Shida Kartli 7.1 5.2 2.7 285Shida Kartli 7.1 5.2 2.7 285 Kvemo Kartli 9.4 7.1 4.9 420 Samtskhe–Javakheti 2.3 2.9 4.4 350 Adjara 16.7 4.2 9.3 317 Guria 15.7 11.2 7.1 290 Samegrelo 0.0 3.3 2.2 326 Imereti 10.7 7.7 5.1 586 Mtskheta–Mtianeti 6.6 5.5 8.3 292 Racha Svaneti 12 8 7 1 3 4 304Racha–Svaneti 12.8 7.1 3.4 304 Education Level Secondary incomplete or less 3.7 1.4 5.0 802 Secondary complete 8.2 6.1 3.9 1,196 Technicum 17.9 10.4 8.8 739 University/postgraduate 12.7 11.4 14.8 1,754 Wealth QuintileWealth Quintile Lowest 4.0 3.7 1.7 788 Second 12.5 4.0 5.9 1,032 Middle 3.9 6.9 6.9 1,017 Fourth 8.5 10.8 10.7 710 Highest 15.9 13.3 19.2 944 Ethnicity Georgian 10.6 8.6 10.3 3,857 Oth 5 7 5 5 4 8 634Other 5.7 5.5 4.8 634 Current Use of Contraception Modern 11.0 7.5 10.4 1,436 Traditional 4.3 6.3 9.0 798 No method 9.9 9.3 9.6 2,257 Ever Had a Routine Gynecologic ExamGynecologic Exam Yes 12.5 10.4 11.4 3,097 No 6.2 3.1 3.0 1,394 * Excludes 2 women who did not remember if they had cervical cancer screening. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 238 Table 13.4.3 Awareness of Human Papilloma Virus (HPV) and HPV Vaccine and Interest in the HPV Vaccine by Selected Characteristics Among Women Aged 15–44 Reproductive Health Survey: Georgia, 2010Reproductive Health Survey: Georgia, 2010 Interest Of the Human Papilloma Virus (HPV) Of the HPV Vaccine In Getting the HPV Vaccine Total 20.8 18.3 29.3 6,292 Residence Characteristic No. of Cases Awareness Residence Urban 28.3 24.1 29.7 2,975 Rural 12.3 11.8 28.8 3,317 Region Kakheti 19.1 19.1 30.9 498 Tbilisi 34.3 28.8 30.3 1,426 Shida Kartli 16.4 11.4 29.4 392 Kvemo Kartli 15.0 12.6 30.4 546 Samtskhe–Javakheti 7.6 8.7 13.5 481Samtskhe Javakheti 7.6 8.7 13.5 481 Adjara 14.9 17.4 34.8 419 Guria 13.6 11.4 34.6 401 Samegrelo 10.3 6.9 22.7 477 Imereti 20.3 18.2 30.9 805 Mtskheta–Mtianeti 18.4 18.4 26.6 393 Racha–Svaneti 9.8 11.5 25.4 454 Age Group 15–19 5.7 8.9 31.9 861 20–24 15.1 14.7 30.7 1,099 25–29 21.5 18.2 29.7 1,191 30–34 27.7 21.0 29.1 1,168 35–39 28.5 25.0 28.4 1,051 40–44 29.9 24.6 25.0 922 Number of Living Children 0 15.0 15.2 29.5 2,276 1 26.8 22.8 31.9 1,286 2 24 8 19 9 28 3 2 0692 24.8 19.9 28.3 2,069 3 or more 21.2 18.4 26.1 661 Education Level Secondary incomplete or less 4.7 6.7 27.5 1,330 Secondary complete 12.0 12.1 25.3 1,568 Technicum 26.5 20.2 28.1 903 University/postgraduate 33.6 28.3 33.2 2,491 Wealth Quintile Lowest 7 6 7 8 24 2 1 093Lowest 7.6 7.8 24.2 1,093 Second 13.1 11.5 28.1 1,385 Middle 14.1 13.9 29.8 1,413 Fourth 21.7 19.3 31.4 1,037 Highest 38.9 32.5 31.1 1,364 Ethnicity Georgian 22.8 20.1 30.7 5,488 Other 7.2 6.9 19.8 804 Current Use of ContraceptionCurrent Use of Contraception Modern 30.4 24.5 32.3 1,436 Traditional 22.4 18.5 29.6 798 No method 17.5 16.4 28.3 4,058 Ever Had a Routine Gynecologic Exam Yes 27.7 21.7 30.2 3,322 No 13.8 14.9 28.3 2,970 FINAL REPORT 239 Table 13.5.1 Knowledge of Tuberculosis (TB) and the Way TB Is Transmitted and Exposure to TB By Selected Characteristics among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010Reproductive Health Survey: Georgia, 2010 Have Heard of TB % Through the Air When Coughing Other Ways Does not Know How TB Spreads From a Family Member Who Has Had TB* From Frequent Contact with Someone Who Has Had TB Characteristic No. of Cases Knowledge of Transmission Exposure to TB Total 94.5 67.3 56.6 12.1 8.7 11.8 6,292 Residence Urban 96.9 74.3 59.2 7.9 6.0 12.3 2,975 Rural 91.7 59.4 53.7 16.8 11.7 11.2 3,317 Region Kakheti 87.0 61.2 46.5 22.0 15.3 12.2 498 Tbilisi 97 1 77 3 63 3 6 9 5 8 13 1 1 426Tbilisi 97.1 77.3 63.3 6.9 5.8 13.1 1,426 Shida Kartli 97.0 71.6 65.1 5.7 8.1 7.7 392 Kvemo Kartli 86.1 57.6 45.3 24.6 17.7 11.4 546 Samtskhe–Javakheti 90.2 44.9 39.3 23.6 12.1 9.0 481 Adjara 98.6 73.9 43.9 4.6 4.1 14.9 419 Guria 97.2 72.4 62.4 7.2 6.6 16.0 401 Samegrelo 96.0 74.3 72.6 6.1 6.7 9.4 477 Imereti 95.6 57.1 57.9 15.3 7.5 10.4 805 Mtskheta–Mtianeti 97 5 65 8 58 7 10 3 7 6 12 9 393Mtskheta–Mtianeti 97.5 65.8 58.7 10.3 7.6 12.9 393 Racha–Svaneti 96.4 63.8 67.9 10.1 6.9 12.3 454 Age Group 15–19 89.2 52.9 40.0 23.5 13.3 8.3 861 20–24 92.4 61.7 51.4 16.1 10.7 10.4 1,099 25–29 95.5 70.2 59.1 10.1 6.9 13.9 1,191 30–34 96.6 72.4 63.6 6.9 6.1 11.6 1,168 35–39 97.4 75.0 64.0 7.3 5.9 13.1 1,051 40–44 97.1 75.0 65.3 6.0 8.3 14.2 92240–44 97.1 75.0 65.3 6.0 8.3 14.2 922 Number of Living Children 92.7 63.4 51.1 9.7 11.1 2,276 0 15.6 1 95.5 71.2 62.6 9.6 8.4 12.8 1,286 2 96.4 69.8 60.2 8.9 6.7 11.9 2,069 3 or more 94.3 68.6 57.4 11.6 10.8 12.4 661 Education Level Secondary incomplete or 86 3 49 6 41 0 25 1 17 1 7 6 1 330Secondary incomplete or less 86.3 49.6 41.0 25.1 17.1 7.6 1,330 Secondary complete 94.9 62.2 54.0 13.6 8.5 11.7 1,568 Technicum 97.6 75.8 65.5 5.6 6.4 13.0 903 University/postgraduate 97.9 77.9 64.2 5.8 4.7 13.8 2,491 Wealth Quintile Lowest 90.7 54.3 55.1 17.9 13.6 13.8 1,093 Second 91.4 59.0 50.0 17.2 11.7 9.6 1,385 Middle 94 6 66 8 56 7 12 6 8 7 10 0 1 413Middle 94.6 66.8 56.7 12.6 8.7 10.0 1,413 Fourth 97.1 73.5 55.6 8.3 6.4 13.5 1,037 Highest 97.1 76.9 63.1 7.2 5.3 12.5 1,364 Ethnicity Georgian 96.7 70.6 60.1 9.0 6.6 12.1 5,488 Other 79.7 45.2 33.4 32.5 22.6 9.6 804 * Includes 36 women who were not sure if they were exposed to TB from a family member. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 240 Ta bl e 13 .5 .2 Aw ar en es s of S ym pt om s of T B by S el ec te d Ch ar ac te ris tic s am on g W om en A ge d 15 –4 4 Re pr od uc tiv e He al th S ur ve y: G eo rg ia 2 01 0 Re pr od uc tiv e He al th S ur ve y: G eo rg ia , 2 01 0 Pr ol on ge d an d Se ve re C ou gh Fe ve r Bl oo d in Sp ut um W ei gh t Lo ss Ti re dn es s/ Fa tig ue Ni gh t Sw ea tin g Co ug hi ng M or e Th an 3 W ee ks Lo ss o f Ap pe tit e Pa in in Ch es t Le th ar gy Ot he r Do es N ot Kn ow To ta l 70 .5 28 .0 27 .2 24 .3 20 .4 13 .6 13 .1 12 .8 4. 6 1. 5 1. 2 11 .7 6, 29 2 Ch ar ac te ris tic Sy m pt om s of T B Sp on ta ne ou sl y M en tio ne d No . o f Ca se s Re si de nc e Ur ba n 75 .7 30 .4 32 .1 27 .2 21 .6 15 .3 16 .0 14 .7 5. 4 1. 9 0. 8 7. 4 2, 97 5 Ru ra l 64 .6 25 .2 21 .7 21 .0 19 .1 11 .7 9. 9 10 .6 3. 7 1. 1 1. 6 16 .6 3, 31 7 Re gi on Ka kh et i 57 .8 17 .7 22 .3 15 .7 16 .3 8. 9 8. 9 8. 5 3. 3 1. 4 0. 2 22 .9 49 8 Tb ilis i 79 .7 32 .0 34 .7 29 .4 23 .4 15 .6 14 .8 15 .6 6. 3 2. 7 0. 6 6. 3 1, 42 6 Sh ida K ar tli 77 7 34 1 17 0 22 3 23 7 13 6 7 7 7 9 5 3 0 6 3 0 6 3 39 2 Sh ida K ar tli 77 .7 34 .1 17 .0 22 .3 23 .7 13 .6 7. 7 7. 9 5. 3 0. 6 3. 0 6. 3 39 2 Kv em o Ka rtl i 58 .9 19 .3 19 .4 20 .9 12 .6 10 .9 11 .0 8. 4 3. 1 1. 1 1. 6 24 .7 54 6 Sa m tsk he –J av ak he ti 53 .9 17 .2 15 .7 12 .4 21 .1 5. 6 1. 7 5. 7 2. 2 0. 3 2. 2 22 .4 48 1 Ad jar a 75 .0 26 .5 30 .2 29 .3 13 .0 16 .3 30 .4 20 .8 8. 5 1. 6 0. 7 3. 7 41 9 Gu ria 79 .0 20 .8 36 .8 32 .0 12 .2 21 .8 7. 6 18 .6 4. 6 1. 2 0. 4 6. 6 40 1 Sa m eg re lo 74 .1 42 .4 35 .0 25 .9 22 .7 12 .3 11 .4 10 .9 1. 5 1. 7 1. 3 5. 9 47 7 Im er et i 65 .2 28 .2 23 .3 22 .1 26 .0 15 .7 11 .0 12 .7 3. 7 0. 5 1. 7 15 .1 80 5 M tsk he ta –M tia ne ti 72 .1 22 .6 24 .0 24 .1 20 .5 8. 6 13 .9 11 .0 2. 9 0. 6 0. 6 5. 9 39 3 M tsk he ta M tia ne ti 72 .1 22 .6 24 .0 24 .1 20 .5 8. 6 13 .9 11 .0 2. 9 0. 6 0. 6 5. 9 39 3 Ra ch a– Sv an et i 74 .2 37 .1 25 .4 21 .8 27 .5 14 .6 10 .8 12 .8 2. 8 1. 6 1. 8 8. 9 45 4 A g e Gr ou p 15 –1 9 58 .0 17 .8 17 .8 15 .6 10 .9 6. 0 8. 4 7. 4 2. 6 1. 0 0. 3 23 .2 86 1 20 –2 4 65 .3 22 .2 23 .8 21 .6 18 .0 10 .3 11 .7 10 .4 3. 2 0. 7 1. 4 15 .3 1, 09 9 25 –2 9 70 .8 29 .7 30 .7 26 .8 22 .0 15 .3 13 .2 12 .5 5. 6 2. 3 0. 9 9. 7 1, 19 1 30 –3 4 74 .7 33 .3 30 .1 25 .5 22 .6 14 .6 13 .6 13 .0 4. 8 0. 8 1. 4 7. 3 1, 16 8 35 –3 9 76 .6 33 .4 33 .0 27 .5 24 .1 17 .7 17 .3 16 .2 5. 7 1. 7 1. 7 7. 1 1, 05 1 40 44 80 9 34 3 29 6 31 0 2 3 19 8 1 8 18 6 6 2 1 0 92 2 40 –4 4 80 .9 34 .3 29 .6 31 .0 27 .3 19 .8 15 .8 18 .7 6. 6 2. 7 1. 5 5. 0 92 2 Nu m be r o f L iv in g Ch ild re n 0 65 .6 24 .9 24 .9 21 .9 17 .9 10 .1 11 .4 10 .2 3. 4 1. 3 1. 0 15 .6 2, 27 6 1 74 .5 32 .1 32 .3 26 .1 23 .4 16 .7 14 .6 16 .0 5. 6 2. 2 0. 5 9. 2 1, 28 6 2 74 .3 29 .5 28 .0 25 .1 21 .6 15 .6 13 .6 14 .2 5. 4 1. 1 2. 0 8. 6 2, 06 9 3 or m or e 71 .6 28 .1 24 .7 28 .2 22 .0 16 .3 16 .2 13 .2 5. 8 2. 0 1. 0 9. 6 66 1 Ed uc at io n Le ve l Se co nd ar y i nc om ple te o r l es s 55 7 18 7 15 7 14 9 11 5 7 0 8 0 7 3 2 4 0 9 0 5 25 3 1 33 0 Se co nd ar y i nc om ple te or le ss 55 .7 18 .7 15 .7 14 .9 11 .5 7. 0 8. 0 7. 3 2. 4 0. 9 0. 5 25 .3 1, 33 0 Se co nd ar y c om ple te 66 .0 22 .7 23 .1 22 .1 15 .8 11 .4 12 .9 11 .4 4. 5 1. 3 1. 7 13 .4 1, 56 8 Te ch nic um 74 .7 33 .9 31 .6 31 .5 27 .7 16 .8 16 .2 17 .5 7. 4 1. 5 2. 2 5. 2 90 3 Un ive rs ity /p os tg ra du at e 80 .4 34 .5 34 .9 28 .7 26 .1 17 .7 15 .3 15 .2 5. 1 2. 0 0. 9 5. 1 2, 49 1 W ea lth Q ui nt ile Lo we st 62 .3 25 .8 21 .7 17 .3 14 .8 11 .0 10 .6 7. 4 3. 2 1. 3 1. 8 17 .2 1, 09 3 Se co nd 62 .2 24 .4 19 .5 19 .1 16 .7 9. 0 9. 2 9. 0 2. 9 0. 6 2. 2 18 .3 1, 38 5 M idd le 69 .3 24 .0 23 .9 25 .1 24 .0 13 .7 11 .3 13 .3 4. 0 1. 3 1. 2 12 .0 1, 41 3 M idd le 69 .3 24 .0 23 .9 25 .1 24 .0 13 .7 11 .3 13 .3 4. 0 1. 3 1. 2 12 .0 1, 41 3 Fo ur th 74 .4 28 .8 30 .6 25 .7 18 .6 16 .4 17 .4 16 .3 5. 7 1. 5 0. 3 7. 7 1, 03 7 Hi gh es t 79 .6 34 .6 36 .4 30 .5 24 .9 16 .4 16 .1 15 .7 6. 6 2. 4 0. 7 6. 3 1, 36 4 Et hn ic it y Ge or gia n 73 .8 30 .3 29 .1 25 .7 21 .7 14 .8 14 .4 13 .8 4. 8 1. 7 1. 2 8. 5 5, 48 8 Ot he r 48 .5 12 .6 14 .7 15 .4 12 .1 5. 9 5. 0 6. 1 3. 7 0. 3 1. 2 32 .6 80 4 FINAL REPORT 241 Table 13.5.3 Awareness That TB Can Be Completely Cured and Perception About the Most Appropriate Treatment Approach for a Person with TB by Selected Characteristics among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010Reproductive Health Survey: Georgia, 2010 % No. of Cases Hospitalization Treatment at Home Hospitalization Followed by Home Treatment Does Not Know Total No. of Cases Characteristic Awareness That TB Can Be Completely Cured Perception About the Most Appropriate Treatment Approach for a Person with TB Total 75.2 6,292 77.8 1.4 12.8 8.0 100.0 6,292 Residence Urban 81.7 2,975 80.7 1.2 13.6 4.5 100.0 2,975 Rural 67.9 3,317 74.5 1.6 11.9 12.0 100.0 3,317 Region Kakheti 60.0 498 68.8 2.1 10.8 18.4 100.0 498 Tbilisi 82.3 1,426 81.9 1.0 13.1 4.0 100.0 1,426 Shid K tli 83 2 392 83 0 1 6 11 6 3 7 100 0 392Shida Kartli 83.2 392 83.0 1.6 11.6 3.7 100.0 392 Kvemo Kartli 61.7 546 71.4 1.4 9.7 17.4 100.0 546 Samtskhe–Javakheti 58.9 481 66.6 1.2 11.0 21.1 100.0 481 Adjara 74.2 419 78.3 2.1 17.6 2.0 100.0 419 Guria 86.6 401 78.4 0.4 17.0 4.2 100.0 401 Samegrelo 78.8 477 80.7 1.0 13.3 5.0 100.0 477 Imereti 79.4 805 79.2 1.4 12.0 7.4 100.0 805 Mtskheta–Mtianeti 76.0 393 78.7 1.5 14.8 4.9 100.0 393 Racha–Svaneti 77 3 454 80 8 1 1 13 7 4 4 100 0 454Racha–Svaneti 77.3 454 80.8 1.1 13.7 4.4 100.0 454 Age Group 15–19 58.5 861 72.5 2.0 8.9 16.6 100.0 861 20–24 69.8 1,099 75.9 1.3 12.4 10.4 100.0 1,099 25–29 78.8 1,191 78.3 1.1 13.9 6.7 100.0 1,191 30–34 82.6 1,168 82.2 0.8 12.5 4.5 100.0 1,168 35–39 82.6 1,051 80.3 1.2 14.3 4.2 100.0 1,051 40–44 82.7 922 78.7 1.8 15.4 4.1 100.0 922 Number of LivingNumber of Living Children 0 69.0 2,276 74.4 1.7 13.4 10.4 100.0 2,276 1 80.4 1,286 80.3 1.2 11.8 6.7 100.0 1,286 2 79.6 2,069 80.1 1.1 13.2 5.6 100.0 2,069 3 or more 78.1 661 80.0 1.4 10.7 8.0 100.0 661 Education Level Secondary incomplete or less 56.7 1,330 72.5 1.1 7.7 18.7 100.0 1,33072.5 1.1 7.7 18.7 100.0 1,330 Secondary complete 72.1 1,568 77.2 1.9 12.3 8.6 100.0 1,568 Technicum 83.1 903 82.0 1.5 13.6 2.9 100.0 903 University/postgraduate 85.3 2,491 79.8 1.2 15.7 3.3 100.0 2,491 Wealth Quintile Lowest 65.0 1,093 71.7 1.9 13.4 12.9 100.0 1,093 Second 67.2 1,385 75.7 1.9 10.5 11.9 100.0 1,385 Middle 73.7 1,413 77.1 1.3 12.5 9.1 100.0 1,413 Fourth 80.4 1,037 80.3 1.1 14.1 4.5 100.0 1,037 Highest 84.7 1,364 81.7 0.9 13.4 4.1 100.0 1,364 Employment Working 86.6 1,410 77.0 1.2 18.6 3.2 100.0 1,410 Not working 72.2 4,882 78.0 1.4 11.2 9.4 100.0 4,882 Ethnicity Georgian 79.6 5,488 79.9 1.4 13.6 5.1 100.0 5,488 Other 46.4 804 63.6 1.3 7.6 27.5 100.0 804 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 242 Table 13.6.1 Percentage of Women Aged 15–44 by Current Smoking Status and by Residence. Reproductive Health Survey: Georgia, 2010 Residence Tbilisi Other Urban Rural Current tobacco smoker 5.5 13.4 4.1 1.7 Daily smoker 4.6 11.3 3.5 1.2 Occasional smoker 0.9 2.1 0.6 0.4 Smoking Status Total Residence Non–smoker 94.5 86.6 95.9 98.3 Former daily smoker 1.3 3.5 0.8 0.2 Never daily smoker 1.1 2.4 0.8 0.5 Never smoker 92.2 80.7 94.3 97.6 Total 100.0 100.0 100.0 100.0 No. of Cases * 6,279 1,417 1,547 3,315 * Exclude 13 women who refused to answer. FINAL REPORT 243 Table 13.6.2 Percentage of Women Aged 15–44 Who Have Ever Smoked and Who Currently Smoke by Selected Characteristics Reproductive Health Survey: Georgia, 2010Reproductive Health Survey: Georgia, 2010 Current Smoker Past Smoker Total 7.8 5.5 2.3 6,292 Residence U b 12 7 8 9 3 8 2 975 Characteristic No. of Cases Current Status Ever Smoked Urban 12.7 8.9 3.8 2,975 Rural 2.4 1.7 0.7 3,317 Region Kakheti 4.5 3.6 0.9 498 Tbilisi 19.2 13.3 5.9 1,426 Shida Kartli 2.8 1.4 1.4 392 Kvemo Kartli 3.1 2.1 1.0 546 Samtskhe–Javakheti 1 4 1 1 0 3 481Samtskhe–Javakheti 1.4 1.1 0.3 481 Adjara 6.1 4.3 1.8 419 Guria 1.0 0.6 0.4 401 Samegrelo 2.8 1.8 1.0 477 Imereti 3.0 2.6 0.4 805 Mtskheta–Mtianeti 5.7 3.2 2.5 393 Racha–Svaneti 2.5 0.9 1.6 454 Age Group 15–19 2.6 2.2 0.4 861 20–24 7.3 4.7 2.6 1,099 25–29 8.4 6.4 2.0 1,191 30–34 10.3 7.0 3.3 1,168 35–39 9.8 6.9 2.9 1,051 40–44 9.5 6.3 3.2 922 Number of Living Children 0 7 0 5 6 1 4 2 2760 7.0 5.6 1.4 2,276 1 13.0 8.4 4.6 1,286 2 6.5 4.2 2.3 2,069 3 or more 5.4 3.2 2.2 661 Education Level Secondary incomplete or less 2.5 2.3 0.2 1,330 Secondary complete 5.7 3.8 1.9 1,568 Technicum 5.6 3.9 1.7 903 University/postgraduate 13.0 8.9 4.1 2,491 Wealth Quintile Lowest 2.1 1.6 0.5 1,093 Second 2.5 1.8 0.7 1,385 Middle 4.0 2.5 1.5 1,413 Fourth 9.6 6.7 2.9 1,037 Highest 16.9 12.0 4.9 1,364 Eth i itEthnicity Georgian 8.4 5.8 2.6 5,488 Other 4.0 3.3 0.8 804 Current Use of Contraception Modern 9.3 5.9 3.4 1,436 Traditional 4.5 3.2 1.3 798 No method 7.9 5.7 2.2 4,058 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 244 Table 13.6.3 Secondhand Smoking at Home and at Work (Indoors) by Selected Characteristics Among All Women and Women Not Currently Smoking Aged 15–44 Reproductive Health Survey: Georgia 2010Reproductive Health Survey: Georgia, 2010 Exposed to Tobacco Smoke at Home No. of Cases Exposed to Tobacco Smoke at Work No. of Cases Exposed to Tobacco Smoke at Home No. of Cases Exposed to Tobacco Smoke at Work No. of Cases All Women Non–Smoker Characteristic Home Work Home Work Total 51.6 6,292 43.6 1,352 49.6 5,823 40.3 1,167 Residence Urban 48.9 2,975 47.0 872 45.4 2,588 43.4 703 Rural 54.5 3,317 35.3 480 53.9 3,235 33.9 464 Age Groupg p 15–24 51.0 1,960 47.3 169 49.8 1,871 43.9 154 25–29 56.0 1,191 40.8 250 54.0 1,102 36.3 217 30–34 52.2 1,168 45.9 260 48.9 1,057 43.2 222 35–39 49.3 1,051 40.8 352 47.5 955 36.2 298 40–44 49.7 922 44.7 321 47.3 838 42.9 276 Education Level Secondary incomplete 52.9 1,330 59.4 48 52.1 1,295 56.0 41Secondary incomplete or less 52.9 1,330 59.4 48 52.1 1,295 56.0 41 Secondary complete 55.7 1,568 55.7 108 54.3 1,493 52.9 95 Technicum 54.4 903 44.4 199 53.0 850 42.6 182 University/postgraduate 47.2 2,491 41.2 997 43.7 2,185 37.4 849 Wealth Quintile Lowest 52.9 1,093 39.3 87 52.1 1,063 37.2 84 Second 56 3 1 385 33 1 200 55 7 1 353 31 0 194Second 56.3 1,385 33.1 200 55.7 1,353 31.0 194 Middle 51.7 1,413 39.9 314 50.5 1,356 37.5 296 Fourth 51.0 1,037 47.9 280 48.6 936 46.3 246 Highest 47.5 1,364 46.5 471 42.6 1,115 41.9 347 Ethnicity Georgian 51.7 5,488 43.7 1,252 49.7 5,054 40.2 1,072 Other 50.4 804 41.5 100 49.1 769 41.6 95 FINAL REPORT 245 Table 13.7 Percentage of Women Aged 15–44 Who Used Alcohol During the Previous Three Months by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Ever Drank CurrentDrinkers Current Frequent Drinkers Binger Total 30.5 16.6 1.8 8.0 6,292 Residence Urban 33.9 18.5 2.3 9.2 2,975 Rural 26.7 14.5 1.2 6.7 3,317 Region Kakheti 32.8 21.8 3.2 8.2 498 Tbilisi 40.9 23.2 3.1 12.3 1,426 Shida Kartli 36.5 15.8 1.4 9.5 392 Kvemo Kartli 19.3 8.9 0.7 5.7 546 Samtskhe–Javakheti 18.6 7.6 0.3 3.1 481 Adjara 13.7 7.3 0.9 3.4 419 Guria 19.8 10.4 0.4 6.2 401 Samegrelo 33.4 19.2 2.2 8.6 477 Imereti 30.7 16.8 0.8 6.4 805 Mtskheta–Mtianeti 34.2 16.5 1.9 6.8 393 Racha–Svaneti 33.2 16.9 2.3 8.5 454 Age Group 15–24 29.0 14.4 1.0 8.6 1,960 25–34 29.4 16.4 1.4 8.6 2,359 35–44 33.7 19.6 3.3 6.9 1,973 Marital Status Married 26.9 14.8 1.4 6.3 4,098 Previously married 36.6 21.7 5.6 14.0 389 Never married 35.7 18.8 1.7 9.9 1,805 Education Level Secondary incomplete or less 24.5 12.0 1.0 6.0 1,330 Secondary complete 26.7 16.2 2.0 8.1 1,568 Technicum 31.1 16.9 1.6 8.8 903 University/postgraduate 36.2 19.4 2.2 9.0 2,491 Wealth Quintile Lowest 26.8 12.9 0.6 6.5 1,093 Second 24.7 14.3 1.0 5.6 1,385 Middle 28.5 16.0 2.2 7.3 1,413 Fourth 28.1 14.8 1.4 7.7 1,037 Highest 40.4 22.2 3.0 11.6 1,364 Ethnicity Georgian 32.6 17.6 2.0 8.8 5,488 Other 16.7 9.8 0.7 3.1 804 Employment Working 39.6 22.5 2.4 8.7 1,410 Not working 28.1 15.0 1.6 7.9 4,882 Characteristic No. of Cases Alcohol Use During the Past Three Months REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 246 Table 13.8 Percentage of Women Aged 15–44 Who Have Ever Been Told by a Doctor That They Have Selected Health Problems by Selected Characteristics Reproductive Health Survey: Georgia, 2010 PID High Blood Pressure Anemia Heart Disease Diabetes Total 19.4 5.5 4.2 2.8 0.6 6,292 Residence Urban 18.6 5.1 4.4 2.4 0.7 2,975 Rural 20.2 6.1 3.9 3.4 0.5 3,317 Region Kakheti 22.6 8.5 5.2 1.1 0.2 498 Tbilisi 18.1 5.4 5.2 2.0 0.8 1,426 Shida Kartli 22.3 7.1 4.3 2.6 0.4 392 Kvemo Kartli 19.3 3.6 4.0 3.1 0.3 546 Samtskhe–Javakheti 17.7 2.8 1.1 2.3 0.0 481 Adjara 16.2 5.9 0.7 5.5 0.2 419 Guria 11.8 5.2 3.0 2.2 0.4 401 Samegrelo 19.3 5.5 2.5 3.9 0.3 477 Imereti 21.7 5.4 5.8 2.8 1.6 805 Mtskheta–Mtianeti 21.9 7.2 5.9 4.6 0.8 393 Racha–Svaneti 22.6 6.4 4.3 3.4 0.4 454 Age Group 15–24 6.5 2.3 2.7 1.4 0.5 1,960 25–34 22.4 4.0 5.3 1.8 0.4 2,359 35–44 31.6 11.2 4.7 5.8 1.0 1,973 Marital Status Married 29.2 7.1 5.2 3.2 0.6 4,098 Previously married 31.6 9.1 5.7 6.4 1.0 389 Never married 0.1 2.2 2.2 1.6 0.6 1,805 Education Level Secondary incomplete or less 13.1 4.8 2.8 3.2 0.4 1,330 Secondary complete 20.8 5.1 3.5 2.7 0.8 1,568 Technicum 26.1 9.3 3.9 5.3 0.8 903 University/postgraduate 19.8 5.0 5.5 1.9 0.6 2,491 Wealth Quintile Lowest 16.6 7.7 3.3 5.5 0.9 1,093 Second 21.7 5.1 2.7 2.4 0.7 1,385 Middle 20.5 6.1 4.8 2.9 0.3 1,413 Fourth 16.8 4.2 3.8 2.1 0.7 1,037 Highest 20.0 5.2 5.5 2.2 0.6 1,364 Ethnicity Georgian 19.5 5.7 4.6 2.9 0.7 5,488 Other 18.6 4.6 1.6 2.7 0.2 804 Employment Working 21.8 6.2 5.1 2.2 0.7 1,410 Not working 18.7 5.4 3.9 3.0 0.6 4,882 Characteristic No. of Cases Selected Health Problems 247 CHAPTER 14 FAMILY LIFE EDUCATION Interests in teenage sexuality, adolescent pregnancy, and sexual health have been increasing worldwide in recent years. It has become clear that complex ap- proaches are required for prevention activities meant to reduce the rates of sexually transmitted infections and early pregnancies among adolescents. For exam- ple, school-based sex education should be an impor- tant component of a wider effort. Health education interventions at school, with a family-based exposure to sex education, are appropriate for promoting teen- age sexual and reproductive health. Various studies from different countries have demonstrated that high- quality sex education programs in school can lead to enhanced understanding of personal hygiene, health, and reproductive issues. In the countries with well- established family life education curricula, age-appro- priate topics from the first to 12th grade are included as a component of the health and physical curriculum. Recently, in Georgia, elements of reproductive biology have been incorporated in high school biology and hu- man anatomy classes, but the curriculum still needs improvement and enhancement. 14.1 Opinions about Family Life Education at Schools Adolescents’ health knowledge and behavior can be improved by providing high quality family life educa- tion in schools. One of the objectives of the GERHS10, as well as of the previous surveys, was to examine whether reproductive-age women in Georgia favor school-based sex education (termed “family life edu- cation” in the region) and to explore their opinions about the best age to start such education. Survey information on exposure to family life education as experienced by young respondents can be used for establishing school curricula and for planning training courses of teachers. In 2010, the large majority of re- spondents (80%) supported sex education at schools. Teaching specific sex education topics, concerning “how pregnancy occurs,” sexually transmitted infec- tions, and contraception, was supported by 80%, 78%, and 76% of respondents respectively (Table 14.1.1, Fig- ure 14.1.1). Support for any sex education at schools was the strongest among women who are employed (86%), have high SES (84%), live in urban areas (83%), have no or one child (82%), are more educated (85%), and are young (81% at ages 15-24). It was the weakest among Azeri women (50%), those with three or more children (69%), and those with lowest SES (lowest wealth quintile) (67%). Those respondents who favored family life education at schools were asked the best age to start teach- ing the above mentioned topics (Tables 14.1.2 and REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 248 14.1.3). Only 12% felt that this should start before the age of 14; 52% felt it should start between 14-15 years of age, and 35% felt it should start only at age 16 or older. The women from certain regions tended to be more conservative about the best age to introduce sex education topics. Slightly more than 40% of respond- ents from Shida Qartli, Adjara, Samtskhe-Javakheti, and Mtskheta-Mtianeti mentioned that waiting until the age of 16 or later was the most appropriate for in- troducing courses on “how pregnancy occurs” and on contraception. Other subgroups also rose above 40% favoring age 16 or later on that topic: women with three or more children, those with a technicum edu- cation, those in the second quintile, and the Armenian and “Other” ethnic groups. These patterns were mirrored by responses about the best age to start courses on contraception: the same regions were conservative on this as were the sub- groups mentioned. Conservative views were found for other topics as well. Only 8% of respondents believed the topic of sexually transmitted infections should be introduced at the age of 13 or earlier; the rest were split evenly between ages 14-15 and 16 or later, at 44% to 48% each. Regarding the regions, more than half of re- spondents from Shida Qartli, Samtskhe-Javakheti, Ad- jara, and Mtskheta-Mtianeti favored the age of 16 or older as best for introducing the course on STIs. Trends on three of these topics appear in Figure 14.1.2. It compares respondents’ opinions in 1999, 2005, and 2010 regarding the best age to start family life courses in schools. In 2010, more women thought that education about “how pregnancy occurs” should start at later ages than was the case in the two previ- ous surveys (top segments of bars in Figure 14.1.2). In all three years the majority of respondents regarded ages 14-15 as the best for introducing this topic, but in 2010 only slightly more than half of respondents gave that response while in 1999 and 2005 more than 80% respondents did so. Closely similar shifts are appar- ent in Figure 14.1.2 for courses on contraception and on STI. All these changes, as with several described earlier, are in a more conservative direction. Figure 14.1.1 Support for family Life Education in Schools by Age, Education and SES 100 80 60 40 20 0 1 5 - 2 4 2 5 - 3 4 3 5 - 4 4 81 80 78 71 75 85 86 67 78 80 85 84 S e c o n d I n c o m p le t e S e c o n d C o m p le t e T e c h n ic u m U n iv e r s it y L o w e s t S e c o n d M id d le F o u r t h H ig h e s t Age Group Education SES Figure 14.1.2 1999 100 80 60 40 20 0 Perceived Best Age to Start family Life Education About Specific Topics in 1999, 2005 and 2010 How Pregnancy Occurs 2005 2010 1999 2005 2010 1999 2005 2010 Contraception STI Yrs. or Less 13-14 Yrs. Yrs. or Older FINAL REPORT 249 14.2 Discussions about Sex Education Topics with Parents To elicit information about family-based exposure to sex education topics, all respondents aged 15-24 were asked whether, before they reached the age of 18, they had ever talked to a parent about such topics as the menstrual cycle, how pregnancy occurs, con- traceptive methods, or HIV/AIDS and others STIs. The data for those aged 15-17 are truncated because they had not reached the age of 18, so the data for this age group should be considered as minimum estimates only. Slightly more than three-fourths (77%) of young re- spondents had discussed at least one sex education topic with a parent (see Table 14.2 for “any topic”). The highest percentages emerged for respondents living in urban areas including Tbilisi, women with no child yet, those with university/postgraduate educa- tion, those in the highest SES (wealth quintile) group, women without sexual experience, and interestingly, those with monthly religious attendance. Remarkably, the youngest ages (15-17) reported higher percentag- es than did the two older age groups despite the trun- cation effect, perhaps signaling a social change toward more open discussions with teenagers. When family life education topics were discussed with a parent, the discussions mostly related to the menstrual cycle (75%), and much less for discussions about how pregnancy occurs (15%), HIV/AIDS (7%), other sexually transmitted infections (4%), or family planning (2%). The age pattern just mentioned oc- curred for discussions about the menstrual cycle, not having sex before marriage, and HIV/AIDS, as the age 20-24 group reported less discussion with parents on these topics. Discussions about HIV/AIDS with parents varied across the various subgroups. It was highest among the resi- dents of Tbilisi (15%) and Mtskheta-Mtianeti (13%), women with high SES (12%), youth aged 15-17, and those with monthly religious attendance, when com- pared to their counterparts. Trends appear in Figure 14.2.1, which shows the dif- ferences between the 1999, 2005, and 2010 surveys for discussions with parents. The largest improve- ment is for the topic of the menstrual cycle, with a 21 point rise from 1999 to 2005, declining only to 75% in 2010. For contraception a rise also occurred in 2005 but it nearly disappeared in 2010. The low levels for the other three topics held fairly steady. 14.3 Family Life Education at Schools The school system provides an environment where young people can have conversations with well-in- formed adults about the issues that are important to their reproductive development. It is an institution to which most young people are connected, and it pro- vides an important opportunity to disseminate con- sistent and accurate information about sexual health topics. The next question explored in the 2010 survey was whether respondents aged 15-24 received formal or informal sexual education in school before age 18. The question asked about specific reproductive health- related topics, such as female and male reproductive biology, the menstrual cycle, how pregnancy occurs, contraceptive methods, and sexually transmitted in- fections, including HIV/AIDS. As with the data on discussions of family life educa- tion topics with parents, the data on school-based education for those aged 15-17 are truncated, since these respondents had not yet reached the age of 18. Consequently, the results for this age group should be considered to be minimum estimates only. Only 46% of young women had at least one school- based course that addressed sex education topics (Ta- ble 14.3). Respondents living in urban areas were more likely to have had such courses than those living in ru- ral areas (50% vs. 41%) (Figure 14.3.1). The percent- ages also varied widely by region, ranging from 31% in Adjara to 55% in Mtskheta-Mtianeti. Prevalence of sex education at school was correlated with respondents’ socioeconomic status (wealth quintile): only 35% of Figure 14.2.1 100 80 60 40 20 0 Percent 1999 2010 Family Life Education Topics Discussed with a Parent Before Reaching Age 18, Among Young Women Aged 15-24 Menstrual Cycle Contarception Pregnancy HIV/AIDS Other STIs 59 80 75 2 19 2 13 17 15 5 8 7 3 2 4 2005 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 250 respondents with the lowest SES reported having had any sex education at school, compared to 45% of mid- dle-SES and 57% of highest-SES respondents. Ethnicity was also a factor: while the respondents of Georgian and Armenian ethnicity showed 48%-49%, only 18% of Azeri respondents were exposed to any sex educa- tion topics at school. Regarding topics, these young women were much more likely to have received lectures on female re- productive biology (41%), male reproductive biology (38%), the menstrual cycle (28%), how pregnancy oc- curs (20%), and HIV/AIDS (17%), than on other sexu- ally transmitted infections (3%) or contraception (3%). For every topic, more urban than rural youth had had school courses. Interestingly, for every sex education topic included in the survey, higher proportions of young women with no sexual experience reported exposure to courses in comparison to their sexually experienced counter- parts, who are generally older. If courses in schools have become more common recently, women aged 15-17, who show the highest exposure on every topic, also dominate the group with no sexual experience. School exposure may help explain why the youngest women also report the most discussion with their par- ents, as documented above. Trends in fact from 1999 to 2010 do show a signifi- cant increase at least for school-based exposure to information on HIV/AIDS (from 5% in 1999 and 3% in 2005 to 17% in 2010), and a slight increase in reported education on contraception (from 1% in 1999 and 2% in 2005 to 3% in 2010). However there has been a de- cline in school-based education on “how pregnancy occurs” (from 32% in 1999 and 25% in 2005 to 20% in 2010). 14.4 Sources of Information on Sexual Matters To learn more about the main sources of information on sexual topics for young women aged 15-24, they were asked who/what had been their most important source of information on sexual matters. They most often named friends (32%) (Table 14.4 and Figure 14.4), and nearly one out of four mentioned that it was a parent (23%). Also, 12% cited radio or television as the most important source. Teachers are of particular interest, related to the discussions above. They ranked overall as the third (10%) most important source of information (after friends and parents), but the percentage was espe- cially high for the youngest women, aged 15-17 (15%). It was high also for the lowest wealth quintile (16%) and for Armenians (13%). It did not vary appreciably Figure 14.3.1 Selected Characteristics of Young Women Who Received Any Family Life Education in School Before Reaching Age 18 by Residence, Number of Children, and SES 100 80 60 40 20 0 U r b a n R u r a l 0 1 2 + L o w e s t S e c o n d M id d le F o u r t h H ig h e s t Residence No. of Children SES 50 41 48 44 31 35 38 45 47 57 Percent Figure 14.3.2 100 80 60 40 20 0 1999 2010 Percentage of Young Women Who had School-Based Education on Specific Family Life Education Topics Before Age 18 in1999, 2005 and 2010 HIV/AIDS Contarception PregnancyOther STIs 5 3 17 2 11 3 1 2 3 32 25 20 2005 FINAL REPORT 251 by residence. However certain regions showed high percentages: Samegrelo (13%), Imereti (13%), and Ra- cha-Svaneti (17%). The reported information sources did not vary much by residence, except that radio and TV were mentioned more by rural respondents. Re- gions varied considerably in the reported reliance on friends, with the highest percentages in Kakheti (43%) and Samegrelo (39%), and also in Shida Kartli (35%) and Samtskhe-Javakheti (35%). In considering all these results it must be remem- bered that they pertain strictly to the woman’s single most important source of information. Most adoles- cents are exposed to multiple sources, but that would require a different analysis and a more complex one. 14.5 Impact on Knowledge about Fertility Issues from Exposure at School or with Parents Correct knowledge of the most fertile time in a wom- an’s cycle is vital to a couple’s ability to assess the risk of pregnancy during unprotected intercourse. Survey information on this is important for programs devoted to the prevention of unintended pregnancies. There- fore the survey included a series of special questions, and the results were related to exposure to school- based or parental sex education. Respondents aged 15-24 were asked 1) when concep- tion is most likely to occur during the menstrual cy- cle; 2) whether breastfeeding increases, decreases, or has no effect on a woman’s risk of getting pregnant; and 3) whether or not it is possible to get pregnant at the first sexual intercourse. The responses are or- ganized in Table 14.5 according to whether or not the respondents discussed these topics with parents or were taught about them at school. Regarding the first question, only a fifth of all young women correctly names the most fertile period (half- way between periods) during a woman’s menstrual cycle. About half of all respondents (52%) said they “don’t know;” and this was essentially the same re- gardless of instruction about the menstrual cycle in school-based courses (52%) or to discussions about it with parents (54%). Considering both the “don’t know” replies and the incorrect replies, an unfortu- nate 79% in both cases lacked correct information. In short, half of each group did not know the answer, and over half of the remainder gave a wrong answer. However the trend by age was somewhat encourag- ing, since the percentage replying correctly rose from 4% to 16% to 31% across the three age groups from 15-17 to 18-19 to 20-24, as shown in Table 14.5. There was a corresponding decline in the percentage saying they did not know. Regarding the second question, only 38% of young respondents knew that breastfeeding can decrease the chance of pregnancy. This percentage was higher among women who had received information on how pregnancy occurs from a parent (44% vs. 37%), and those who were taught about it at school (45% vs. 37%). High percentages said they did not know, but they were lower in the groups with exposure. Con- sequently that left more respondents with exposure to fall into the “no effect” group than for respondents without exposure. In fact, more of those with expo- sure gave correct replies. Once again, the age patterns are mildly encouraging: the percentage replying correctly rose from 16% to 30% to 54% across the three age groups in the table, and the percentage not knowing declined. Finally, for the third question, the large majority of young women correctly confirmed the possibility of getting pregnant during a woman’s first sexual inter- course. Having conversation about pregnancy with a parent raised the percent to 82% (yes) from 71% (no) for an 11 point improvement. However the difference was not significant for school exposure: 74% (yes) vs. 73% (no). Knowledge increased with age with 56% of those aged 15-17 to 73% of those aged 18-19 to 82% of those aged 20-24 giving the correct response. Figure 14.4 Most Important Source of Information About Sexual Matters Among Women Aged 15-24 Years, 2010 32 9 5 9 12 23 10 Friends Mother/Father Radio/TV Teacher Books Doctors Other REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 252 Table 14.1.1 Percentage of Women Aged 15–44 Who Agree That Selected Sex Education Topics Should Be Taught in School Reproductive Health Survey: Georgia, 2010 Any Family Life Education How Pregnancy Occurs Sexually Transmitted Infections (STIs) Contraception Total 79.5 79.5 77.6 76.4 6,292 Residence Urban 83.1 83.1 81.6 80.9 2,975 Rural 75.5 75.5 73.1 71.3 3,317 Region Kakheti 72.9 72.9 69.8 66.3 498 Tbilisi 81.8 81.8 80.6 80.0 1,426 Shida Kartli 85.0 85.0 84.8 82.6 392 Kvemo Kartli 71.9 71.9 68.1 66.7 546 Samtskhe–Javakheti 82.5 82.3 78.7 77.6 481 Adjara 72.8 72.8 72.6 72.6 419 Guria 71.6 71.6 71.2 69.2 401 Samegrelo 86.4 86.4 82.9 81.2 477 Imereti 83.6 83.6 81.8 80.9 805 Mtskheta–Mtianeti 78.1 78.1 76.6 74.7 393 Racha–Svaneti 76.7 76.7 75.0 73.5 454 Age Group Family Life Education Topics Characteristic No. of Cases Age Group 15–24 81.1 81.1 78.6 77.5 1,960 25–34 79.6 79.5 78.0 77.1 2,359 35–44 77.6 77.6 76.0 74.3 1,973 Number of Living Children 0 82.0 82.0 79.5 78.3 2,276 1 82.4 82.4 80.3 79.2 1,286 2 77.7 77.7 76.6 75.4 2,069 3 or more 69.6 69.6 68.4 66.3 661 Education Level Secondary incomplete or less 70.8 70.8 68.1 66.8 1,330 Secondary complete 74.7 74.7 72.1 70.9 1,568 Technicum 84.9 84.9 83.4 80.9 903 University/postgraduate 85.8 85.8 84.6 83.9 2,491 Wealth Quintile Lowest 67.4 67.4 65.8 63.4 1,093 Second 77.5 77.5 74.0 72.9 1,385 Middle 79.7 79.7 77.8 76.4 1,413 Fourth 84.9 84.9 83.6 82.2 1,037 Highest 84.0 84.0 82.6 82.2 1,364 Ethnicity Georgian 81.8 81.8 80.2 78.9 5,488 Azeri 49.7 49.7 46.1 45.8 276 Armenian 74.0 74.0 68.8 66.9 364 Other 75.4 75.4 73.9 73.7 164 Employment Working 86.1 86.1 84.5 84.1 1,410 Not working 77.8 77.8 75.8 74.3 4,882 FINAL REPORT 253 Table 14.1.2 Perceived Best Age to Start Family Life Education on "How Pregnancies Occur" and on Contraceptive Methods Among Women Aged 15–44 Who Agreed with Sex Education in School. Reproductive Health Survey: Georgia, 2010 ≤13 14–15 16+ ≤13 14–15 16+ Total 12.2 52.7 35.0 100.0 4,982 7.9 44.3 47.8 100.0 4,796 Residence Urban 13.1 52.8 34.1 100.0 2,466 7.7 44.7 47.5 100.0 2,405 Rural 11.2 52.7 36.1 100.0 2,516 8.0 43.8 48.2 100.0 2,391 Region Kakheti 16.9 53.8 29.3 100.0 360 11.5 43.2 45.3 100.0 330 Tbilisi 15.1 53.9 31.0 100.0 1,172 8.8 44.8 46.4 100.0 1,153 Shida Kartli 8.8 49.7 41.5 100.0 335 6.7 36.8 56.6 100.0 324 Kvemo Kartli 15.1 55.9 29.0 100.0 385 13.3 50.1 36.6 100.0 362 Samtskhe–Javakheti 6.4 50.8 42.8 100.0 403 4.4 37.2 58.4 100.0 382 Adjara 3.2 39.0 57.8 100.0 304 1.0 33.5 65.5 100.0 303 Guria 15.9 58.1 26.0 100.0 280 9.2 42.5 48.3 100.0 271 Samegrelo 12.6 57.2 30.2 100.0 417 6.6 50.5 42.9 100.0 393 Imereti 11.2 55.4 33.3 100.0 670 7.5 50.2 42.3 100.0 651 Mtskheta–Mtianeti 10.9 47.2 41.8 100.0 305 6.9 39.2 53.9 100.0 291 Racha–Svaneti 13.7 58.6 27.8 100.0 351 12.6 45.7 41.8 100.0 336 Age Group 15–24 12.3 55.7 32.0 100.0 1,577 8.3 47.6 44.1 100.0 1,516 25–34 12.2 51.4 36.4 100.0 1,862 6.9 43.1 50.0 100.0 1,796 35–44 12.1 50.4 37.4 100.0 1,543 8.4 41.5 50.1 100.0 1,484 Number of Living Children 0 12.0 55.9 32.1 100.0 1,858 8.0 47.0 45.0 100.0 1,783 1 14.3 51.3 34.3 100.0 1,043 8.7 43.5 47.8 100.0 1,001 2 11.4 50.6 38.1 100.0 1,613 7.0 42.5 50.5 100.0 1,563 3 or more 11.4 48.0 40.6 100.0 468 8.3 39.5 52.3 100.0 449 Education Level Secondary incomplete or less 11.7 53.5 34.8 100.0 924 9.1 45.5 45.4 100.0 873 Secondary complete 11.4 52.9 35.8 100.0 1,178 8.5 43.2 48.2 100.0 1,126 Technicum 11.6 46.6 41.8 100.0 757 6.1 41.1 52.7 100.0 726 University/postgraduate 13.2 54.4 32.5 100.0 2,123 7.5 45.4 47.1 100.0 2,071 Wealth Quintile Lowest 12.8 51.1 36.0 100.0 760 8.1 43.7 48.2 100.0 716 Second 10.2 49.7 40.1 100.0 1,071 8.1 40.7 51.2 100.0 1,018 Middle 12.6 54.5 32.9 100.0 1,132 8.2 46.5 45.2 100.0 1,092 Fourth 11.4 51.9 36.7 100.0 869 6.6 41.3 52.1 100.0 842 Highest 13.7 54.8 31.5 100.0 1,150 8.2 47.5 44.3 100.0 1,128 Ethnicity Georgian 11.8 53.5 34.7 100.0 4,449 7.1 45.3 47.6 100.0 4,297 Azeri 28.2 48.3 23.5 100.0 130 27.7 44.0 28.3 100.0 121 Armenian 6.6 49.4 44.0 100.0 277 5.2 34.5 60.2 100.0 256 Other 17.0 38.5 44.5 100.0 126 14.2 30.0 55.8 100.0 122 No. of Cases No. of Cases Best Age to Start Courses on ContraceptionCharacteristic Best Age to Start Courses on "How Pregnancies Occur" Total Total REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 254 Table 14.1.3 Perceived Best Age to Start Family Life Education about Sexually Transmitted Infections Among Women Aged 15–44 Who Agreed with Sex Education in School. Reproductive Health Survey: Georgia 2010 ≤13 14–15 16+ Total 8.0 44.3 47.7 100.0 4,874 Residence Urban 8.3 44.3 47.4 100.0 2,424 Rural 7.6 44.4 48.0 100.0 2,450 Region Kakheti 11.8 46.3 42.0 100.0 347 Tbilisi 9.4 43.8 46.8 100.0 1,158 Shida Kartli 7.0 37.9 55.1 100.0 334 Kvemo Kartli 13.2 50.9 35.8 100.0 368 Samtskhe–Javakheti 4.3 35.5 60.2 100.0 388 Adjara 1.0 34.7 64.3 100.0 303 Guria 10.7 43.5 45.8 100.0 278 Samegrelo 5.5 49.3 45.2 100.0 400 Imereti 7.4 49.8 42.8 100.0 657 Mtskheta–Mtianeti 6.5 39.5 54.1 100.0 299 Racha–Svaneti 11.6 45.0 43.4 100.0 342 Age Group 15–24 8.1 48.3 43.6 100.0 1,536 25–34 7.4 42.4 50.2 100.0 1,827 35–44 8.5 41.4 50.1 100.0 1,511 Children 0 7.8 46.9 45.3 100.0 1,812 1 9.5 43.8 46.7 100.0 1,016 2 6.9 42.1 51.0 100.0 1,584 3 or more 8.8 40.7 50.5 100.0 462 Education Level or less 8.8 45.8 45.4 100.0 897 Secondary complete 8.1 43.3 48.6 100.0 1,139 Technicum 6.7 40.8 52.5 100.0 745 e 7.9 45.3 46.7 100.0 2,093 Wealth Quintile Lowest 7.6 43.7 48.7 100.0 744 Second 8.3 40.2 51.5 100.0 1,035 Middle 8.3 47.3 44.4 100.0 1,107 Fourth 6.3 41.4 52.3 100.0 856 Highest 8.9 47.2 43.9 100.0 1,132 Ethnicity Georgian 7.3 45.2 47.5 100.0 4,367 Azeri 28.0 43.8 28.2 100.0 122 Armenian 5.1 33.7 61.2 100.0 262 Other 14.1 32.8 53.1 100.0 123 No. of CasesCharacteristic Best Age to Start Courses on STIs Total FINAL REPORT 255 Table 14.2 Percentage of Young Adult Women Aged 15–24 Who Discussed Selected Family Life Education Topics with a Parent Before They Reached Age 18 Reproductive Health Survey: Georgia, 2010 Any Topic MenstrualCycle Not Having Sex Before Marriage How Pregnancy Occurs HIV/AIDS ContraceptiveMethods Other STIs Total 76.8 74.9 16.6 14.9 7.2 2.0 3.7 1,960 Residence Urban 79.9 78.0 18.1 18.3 9.9 2.6 4.9 937 Rural 73.3 71.4 14.9 10.9 4.1 1.4 2.4 1,023 Region Kakheti 69.5 69.5 12.2 8.5 6.9 0.8 2.4 163 Tbilisi 80.2 78.9 19.0 19.8 14.6 3.9 7.2 451 Shida Kartli 78.2 73.9 20.7 17.6 1.6 0.0 0.5 133 Kvemo Kartli 71.7 70.2 11.3 11.3 6.4 0.8 3.4 181 Samtskhe–Javakheti 76.5 76.5 11.6 11.2 2.2 2.2 1.1 171 Adjara 79.2 74.3 25.2 23.3 4.0 2.5 4.0 131 Guria 89.5 89.5 9.2 8.5 7.8 2.6 2.6 104 Samegrelo 82.5 77.2 20.4 12.1 2.9 1.5 0.0 139 Imereti 72.0 71.4 13.3 10.8 2.5 0.6 2.0 251 Mtskheta–Mtianeti 77.6 76.0 11.5 9.8 13.1 4.4 8.7 121 Racha–Svaneti 71.3 67.4 14.0 6.2 2.8 2.2 0.0 115 Age Group 15–17 80.3 78.5 15.8 12.1 11.1 2.0 4.9 481 18–19 78.6 77.8 19.2 17.4 7.8 1.8 3.6 380 20–24 74.2 71.8 16.0 15.3 4.9 2.1 3.1 1,099 Number of Living Children 0 78.0 76.6 16.0 14.5 8.3 2.0 4.2 1,379 1 74.7 71.1 19.6 17.2 4.1 2.3 2.8 396 2 or more 68.6 65.6 15.8 13.7 3.2 1.1 1.1 185 Education Level Secondary incomplete or less 72.7 70.9 14.0 10.1 9.1 1.6 4.1 651 Secondary complete 77.5 75.7 17.4 17.3 5.5 1.6 2.5 604 Technicum 75.0 70.2 16.8 9.9 3.3 0.6 1.2 165 University/postgraduate 81.7 80.4 18.9 19.5 7.9 3.3 5.3 540 Wealth Quintile Lowest 68.8 65.9 10.8 10.6 2.7 0.7 0.6 327 Second 72.7 70.3 14.4 9.4 4.7 1.6 2.5 448 Middle 76.1 75.0 17.3 10.8 3.6 1.6 2.5 433 Fourth 78.7 77.6 18.3 21.6 11.1 3.0 5.9 336 Highest 83.6 81.4 19.6 19.8 11.8 2.7 5.6 416 Ethnicity Georgian 78.9 76.9 17.1 15.5 7.8 2.1 3.9 1,688 Azeri 57.1 56.3 9.3 6.1 2.1 0.0 0.0 92 Armenian 71.1 69.1 15.1 10.8 6.3 3.0 4.7 135 Other 61.4 59.9 19.5 23.1 0.0 1.8 3.4 45 Sexually Experienced No 78.7 77.4 16.0 13.4 8.5 1.8 4.0 1,188 Yes 72.9 69.7 18.0 17.8 4.6 2.5 3.1 772 Religious Attendance Monthly 80.3 78.2 17.9 16.1 9.9 2.9 5.0 882 Less than monthly 74.2 73.2 12.0 14.5 7.7 1.4 3.8 248 Holidays only 76.5 74.8 16.9 14.3 5.0 1.4 2.6 673 Never 61.5 58.5 14.9 10.3 0.5 0.6 1.1 157 Family Life Education Topic Characteristic No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 256 Table 14.3 Percentage of Young Adult Women Aged 15–24 Who Were Taught Family Life Education Topics in School Before They Reached Age 18 Reproductive Health Survey: Georgia 2010 Any Topic Female Reproductive Biology Male Reproductive Biology Menstrual Cycle How Pregnancy Occurs Other STDs HIV/AIDS Contra- ception Total 45.7 40.5 38.1 28.1 19.6 3.1 16.6 2.7 1,960 Residence Urban 49.9 42.6 39.5 32.2 21.0 4.4 20.6 3.5 937 Rural 40.8 38.1 36.6 23.4 18.0 1.6 12.0 1.7 1,023 Region Kakheti 47.6 45.5 45.5 26.8 18.7 2.4 12.6 1.2 163 Tbilisi 54.7 45.7 42.9 35.8 23.2 4.3 21.1 3.5 451 Shida Kartli 43.6 39.9 37.2 20.7 16.0 2.1 14.4 0.5 133 Kvemo Kartli 37.4 32.8 29.8 26.8 16.2 5.3 15.5 3.0 181 Samtskhe–Javakheti 44.0 37.3 35.4 24.3 11.6 1.5 10.8 1.1 171 Adjara 30.7 29.2 27.2 22.3 22.3 2.5 7.4 5.0 131 Guria 33.3 32.0 31.4 20.3 17.6 2.0 14.4 2.0 104 Samegrelo 42.7 37.4 32.5 18.9 18.4 1.9 16.0 1.5 139 Imereti 47.9 44.2 43.3 29.7 19.5 2.0 22.7 3.1 251 Mtskheta–Mtianeti 55.2 48.6 41.5 31.1 21.3 2.2 13.1 0.0 121 Racha–Svaneti 33.7 32.6 32.6 27.5 18.5 2.2 8.4 0.6 115 Age Group 15–17 50.1 45.0 42.2 30.6 21.2 3.8 21.3 2.7 481 18–19 46.3 39.4 37.8 25.0 19.7 2.7 18.5 2.1 380 20–24 43.1 38.5 36.0 28.0 18.7 2.9 13.3 2.8 1,099 Number of Living Children 0 47.5 41.9 39.6 29.3 20.0 3.3 18.3 2.8 1,379 1 43.7 38.7 36.7 26.4 20.4 2.6 12.5 2.5 396 2 or more 30.9 29.6 25.6 19.2 13.0 8.1 2.3 1.7 185 Education Level Secondary incomplete or less 41.1 37.0 34.8 24.2 18.5 3.0 15.5 2.3 651 Secondary complete 48.1 41.9 39.8 28.4 17.1 2.3 18.9 1.9 604 Technicum 50.3 49.7 46.2 28.0 25.2 3.8 9.8 5.0 165 University/postgraduate 47.6 40.7 38.2 32.7 22.2 3.8 17.5 3.3 540 Wealth Quintile Lowest 34.8 32.6 29.9 20.1 18.3 1.0 10.2 2.3 327 Second 38.1 35.0 34.3 22.4 14.6 1.0 11.6 1.1 448 Middle 45.3 42.2 39.9 22.6 19.2 2.5 13.3 2.0 433 Fourth 46.5 38.6 37.0 31.9 19.4 3.8 19.4 3.0 336 Highest 57.4 49.3 45.1 38.6 24.8 5.8 24.7 4.3 416 Ethnicity Georgian 47.9 42.3 39.9 29.2 20.5 3.5 18.4 2.9 1,688 Azeri 17.6 17.6 17.6 11.7 13.1 0.0 2.1 0.0 92 Armenian 48.7 42.9 40.8 30.7 14.9 0.6 9.7 3.0 135 Other 24.0 22.5 16.5 18.7 14.7 1.5 3.5 0.0 45 Sexually Experienced No 48.4 42.7 40.5 30.1 20.2 3.4 19.1 2.9 1,188 Yes 40.1 35.9 33.2 23.9 18.4 2.4 11.4 2.2 772 Religious Attendance Monthly 52.1 45.2 42.4 33.0 22.0 4.2 23.2 3.5 882 Less than monthly 52.7 45.1 43.5 28.2 18.5 1.6 17.1 1.8 248 Holidays only 38.2 35.3 32.8 23.5 16.8 2.5 10.9 2.2 673 Never 29.7 27.8 27.4 18.7 19.3 1.6 1.9 0.6 157 * Less than 25 cases. Family Life Education Topic Characteristic No. of Cases FINAL REPORT 257 Table 14.4 Most Important Source of Information About Sexual Matters Among Young Adult Women Aged 15–24, by Selected Characteristics Reproductive Health Survey: Georgia 2010 Friends Mother/Father Radio/ TV Teacher Books/ Prints Doctor/ Nurse Other Relatives Partner/ Boyfriend Does Not Remember Other Total 31.9 23.1 11.6 9.8 8.7 5.2 2.3 1.2 2.9 3.3 100.0 1,960 Residence Urban 31.1 24.2 9.9 9.7 9.4 5.5 1.8 1.2 2.7 4.5 100.0 937 Rural 32.8 21.8 13.4 10.0 8.0 4.9 2.9 1.3 3.0 1.9 100.0 1,023 Region Kakheti 42.7 15.0 13.4 5.3 7.7 2.4 6.5 0.8 3.3 2.8 100.0 163 Tbilisi 33.0 22.7 10.1 10.7 8.1 5.1 1.9 0.7 2.2 5.6 100.0 451 Shida Kartli 35.1 18.1 13.3 11.7 10.6 6.4 2.1 1.1 0.0 1.6 100.0 133 Kvemo Kartli 24.5 23.4 13.2 9.1 6.8 6.4 5.3 4.2 5.7 1.5 100.0 181 Samtskhe–Javakheti 34.7 14.2 7.1 11.9 8.6 4.1 1.1 2.2 5.6 10.4 100.0 171 Adjara 25.2 41.6 11.4 4.0 3.0 9.9 0.0 0.5 1.5 3.0 100.0 131 Guria 24.8 34.0 17.6 1.3 11.1 6.5 1.3 0.7 0.7 2.0 100.0 104 Samegrelo 38.8 20.4 14.6 12.6 5.3 4.9 1.5 1.0 0.5 0.5 100.0 139 Imereti 28.0 22.1 10.2 13.3 16.7 3.1 0.8 0.6 4.2 0.8 100.0 251 Mtskheta–Mtianeti 31.7 21.3 12.0 8.7 6.0 8.2 3.8 1.6 4.9 1.6 100.0 121 Racha–Svaneti 29.2 24.2 14.6 17.4 9.0 0.0 4.5 0.0 0.6 0.6 100.0 115 Age Group 15–17 30.8 25.8 11.9 14.7 7.0 3.2 1.4 0.2 2.0 2.9 100.0 481 18–19 30.8 27.1 9.7 9.7 7.8 4.8 1.6 0.9 3.1 4.4 100.0 380 20–24 32.9 19.9 12.1 7.3 10.0 6.5 3.1 1.9 3.2 3.0 100.0 1,099 Number of Living Children 0 32.8 23.7 11.6 10.7 8.8 3.9 1.7 0.4 2.8 3.5 100.0 1,379 1 31.0 21.4 11.5 7.2 8.5 10.1 3.2 3.0 1.7 2.5 100.0 396 2 or more 23.8 19.5 11.7 6.6 7.7 8.1 7.8 5.8 6.5 2.4 100.0 185 Education Level Secondary incomplete or less 31.2 24.0 12.4 11.4 5.8 4.7 2.4 1.4 4.0 2.6 100.0 651 Secondary complete 36.3 23.4 9.2 9.4 8.1 4.0 3.6 1.6 1.9 2.4 100.0 604 Technicum 29.2 19.6 12.7 12.2 9.3 8.4 1.5 1.6 3.9 1.6 100.0 165 University/postgraduate 28.6 22.4 12.8 7.7 12.8 6.4 1.1 0.5 2.1 5.6 100.0 540 Wealth Quintile Lowest 30.9 19.9 11.5 16.4 5.0 5.6 4.7 1.0 3.8 1.3 100.0 327 Second 30.4 23.4 16.6 6.7 8.1 5.8 2.6 2.4 2.1 1.9 100.0 448 Middle 36.2 19.1 9.8 10.2 11.0 4.1 2.0 1.2 4.1 2.3 100.0 433 Fourth 32.3 28.4 10.3 7.1 8.9 3.8 1.6 0.7 3.5 3.3 100.0 336 Highest 29.8 23.7 9.9 10.6 9.1 6.6 1.8 0.8 1.5 6.2 100.0 416 Ethnicity Georgian 32.6 23.8 11.4 10.0 9.1 5.1 1.4 0.8 2.4 3.3 100.0 1,688 Azeri 29.6 18.9 17.2 6.7 0.0 3.0 11.1 2.4 9.0 2.2 100.0 92 Armenian 22.8 15.8 8.0 13.4 12.1 10.8 3.3 6.5 2.7 4.5 100.0 135 Other 34.3 24.7 13.0 1.8 4.1 0.0 13.9 1.8 5.0 1.5 100.0 45 Sexually Experienced No 32.8 24.1 11.6 11.1 8.9 3.2 1.6 0.0 3.0 3.7 100.0 1,188 Yes 30.0 20.9 11.5 7.1 8.3 9.5 3.8 3.8 2.6 2.4 100.0 772 Religious Attendance Monthly 35.8 21.1 10.6 10.2 10.8 2.9 1.5 0.6 2.2 4.2 100.0 882 Less than monthly 33.9 20.9 10.8 12.3 6.7 6.6 1.2 1.2 2.3 4.2 100.0 248 Holidays only 25.6 26.4 12.7 9.5 7.8 7.9 2.8 2.0 3.4 1.9 100.0 673 Never 33.2 23.1 13.6 5.2 3.6 5.8 7.1 1.4 5.0 2.0 100.0 157 No. of CasesCharacteristic Most Important Source of Information Total REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 258 Table 14.5 Knowledge Among Young Adult Women Aged 15–24 Regarding Selected Reproductive Health Issues by Whether or Not Specific Family Life Education Topics Were Discussed with a Parent or Taught in School and by Age Group Reproductive Health Survey: Georgia, 2010 Yes % No % Yes % No % 15–17 % 18–19 % 20–24 % Halfway 20.6 21.3 18.5 21.4 20.2 4.1 16.1 31.3 Before Period 17.8 18.2 16.7 16.6 18.3 7.7 18.3 23.1 Any time 9.6 9.1 11.1 10.8 9.2 10.5 9.8 9.1 Do not Know 52.0 51.4 53.7 51.1 52.3 77.7 55.8 36.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,960 1,470 490 525 1,435 481 380 1,099 Yes % No % Yes % No % 15–17 % 18–19 % 20–24 % Lower Risk 38.4 44.0 37.4 44.8 36.9 16.1 29.8 54.0 Has no effect 15.8 21.2 14.8 17.7 15.3 13.1 16.9 16.8 Higher Risk 0.6 0.5 0.6 0.4 0.6 0.0 1.3 0.6 Do not know 45.2 34.2 47.1 37.1 47.2 70.8 52.0 28.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,960 285 1,675 368 1,592 481 380 1,099 Yes % No % Yes % No % 15–17 % 18–19 % 20–24 % Possible 72.9 82.1 71.3 74.3 72.5 55.9 73.4 81.9 Not possible 5.4 5.0 5.5 5.0 5.5 4.8 4.6 6.1 Do not know 21.7 12.9 23.2 20.6 22.0 39.3 22.0 12.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,960 285 1,675 368 1,592 481 380 1,099 Risk of Getting Pregnant While Breastfeeding Total Age Group Taught about "How Pregnancy Occurs" in School Age Group Most Likely Time to Become Pregnant During Menstrual Cycle Age Group Exposure to Family Life Education Discussed Menstrual Cycle With a Parent Taught about Menstrual Cycle in School Discussed "How Pregnancy Occurs" With a Parent Total Discussed "How Pregnancy Occurs" With a Parent Taught about "How Pregnancy Occurs" in School Reproductive Health Issue Total Possibility of Getting Pregnant at First Intercourse 259 CHAPTER 15 YOUNG ADULTS SEXUAL AND CON- TRACEPTIVE EXPERIENCE The 2010 Georgia Reproductive Health Survey (RHS) included a module that was administered to adoles- cent and young adult women aged 15–24, to assess their sexual and reproductive behaviors, particularly regarding their risks of unintended pregnancy and sexually transmitted infections. This chapter explores several findings for this population in relation to sexu- al experience, contraceptive use, and sexual partners. All of these findings can be valuable for planning pro- gram strategies and sex education for young people. 15.1 Sexual Experience In 2010, sexual experience was reported by nearly a third (32%) of young women aged 15-24, almost all of it after marriage (Table 15.1.1). Eleven percent of the adolescent sub-group (15-19 years old) reported sexual experience, compared to 52% of young adults (20-24 years old). The delay in sexual activity until marriage, into the later young adulthood years, was found also in the surveys conducted in 1999 and 2005 (Figure 15.1.1). In Table 5.1.2 sexual experience was lower among young women in Tbilisi (30%) than in other urban areas (33%) or rural areas (35%). Sexual experience increased with education, except for young women with university or postgraduate education, of whom 66% were inexperienced, again related to the age at marriage. Sexual experience was reported more fre- quently by Azeri women (53%) than by women of oth- er ethnic groups (30% of ethnic Georgians, 36% of Ar- menians, and 45% of all others). Premarital sex at first intercourse was highly uncommon, reported by less than 5% of women in any age, residential, education, wealth, or ethnic category, and by only 2% overall. A life table methodology was used to show differenc- es in age at first sexual intercourse across residence, education, socioeconomic status, wealth quintile, and ethnic groups (Table 15.1.3). Overall, there was a steady increase from less than 1% of young women initiating sex before age 15 up to 62% who had done so by age 24. One of the most significant differences occurs across educational levels (Figure 15.1.2). Well over half (60%) of those with secondary education or less had engaged in sexual activity prior to age 22, whereas only 39% with university or technicum edu- cation had done so. The majority of young women, regardless of educational level, had sexual experience by age 24 (66% of women with incomplete secondary education, 74% of women who had completed sec- ondary education and 53% of women with technicum REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 260 or university education). Respondents in the lower two wealth quintiles tended to initiate sex at earlier ages, compared to wealthier young women. Georgian and Armenian young women more fre- quently reported never having sex (70% and 64%, re- spectively); however, Azeri women who did have sex- ual experience tended to have their first intercourse at younger ages than women of other ethnicities. This may be explained by ethnic differences in average age of marriage. Table 15.1.4 separates the two age groups under dis- cussion and permits a focus just on ages 20-24. By that time many more young women are married, and the pattern still holds of very little sexual experience before marriage. Educational attainment is also more nearly complete by ages 20-24 (note in the last col- umn of the table that there are 507 cases of 15-19 year olds with incomplete education but only 82 cases with university education). The pattern of sexual experience according to educa- tion is strongly affected by the age at marriage, which is earlier among the low-education group. This pro- duces an inverse relationship between level of educa- tion and sexual experience. Moving from the lowest to the highest education level, just for the 20-24 age group, the percentage with experience declines from 66% to 63% to 51% to only 40%. 15.2 Partner at First Intercourse Table 15.2.1 depicts the age difference between re- spondents and their partners (most of them mar- ried) at first sexual intercourse. The majority of young women in Georgia (54%) had partners who were less than five years older. Young women in rural areas more often reported having had a partner who was five to ten years older (39%) compared to urban resi- dents (34% and 36%). Regarding the small percentag- es with partners over 10 years older, this was slightly more common in Tbilisi and in rural areas (6.3% and 6.2%, respectively), compared to 4.3% in other urban areas. The disparity between the respondent’s and her partner’s age appeared to be widest among young women who were less than 18 years old at first inter- course: less than half (49%) had partners who were less than 5 years older unlike their counterparts (54% and 59%) (Figure 15.2.1). Table 15.2.2 describes the respondents’ relationship with her partner at first intercourse. As mentioned previously, the majority of young adults reported that their first sexual experience was marital; thus, partners at first sex were predominately husbands (95%), and more than 90% of all regional, educational, wealth, or ethnic groups reported their husband as the first sex partner. Among the 5% who were not married at the time of first intercourse, the majority were engaged Figure 15.1.1 Sexual Experience Among Women Aged 15-24 by Age Group; 1999, 2005 and 2010 1999 2010 2005 Total 33 30 32 10 5 14 27 26 29 40 38 49 62 55 62 15-17 18-19 20-21 22-24 FINAL REPORT 261 to be married to the partner (53%) (2.8%/5.3%). The husband as first partner was reported slightly less of- ten by those living in Tbilisi (91%), by those with least education (93%), and by those of Azeri ethnicity (92%). Most young women had dated their partner for at least 6 months prior to the first sexual intercourse: only 24% dated for less than 6 months. The intervals were considerably spread out: another 14% dated for 6 to 11 months, 25% for 12 to 23 months, and 31% for 24 to 71 months (Table 15.2.3). There were only 40 cases of unmarried respondents; 60% of those re- ported premarital sex after dating their partner for up to 23 months. 15.3 Contraceptive Use at First Intercourse, Current Sexual Activity and Contraceptive Use Contraceptive use at first sexual intercourse is uncom- mon in Georgia, regardless of marital status. The pri- mary reason given by married respondents for not us- ing a contraceptive method at first intercourse wanted to get pregnant (69%). Also important for them was not thinking about using a method (22%). A few said that sex was not expected then, or that they did not know about contraception (2% and 3% respectively) (Table 15.3.1). The primary reasons were quite different for the 34 cases of unmarried respondents. Only 12% wanted to get pregnant, while 51% said that they did not think about contraception or that the sexual encounter was unexpected (19%) (Figure 15.3.1). Unfortunately, a full tenth of young women (10%) who were unmar- ried at the time of first intercourse did not know about contraception. Current sexual activity is an important indicator for determining exposure to the risk of pregnancy, and it has implications for what method of contraception is most appropriate for an individual’s reproductive be- havior and intentions. The majority of married young women (61%) reported being sexually active within the last month. None of this group was pregnant or postpartum, suggesting a high probability of concep- tion in the near future (Table 15.3.2). The cultural de- sire for a child soon after marriage is reflected in the high proportion (34%) who is currently pregnant or postpartum. Among the 35 cases of previously mar- ried young women, both sexual activity and pregnan- cy were relatively uncommon. Table 15.3.3 shows that contraceptive use among young women is not common: among those married Figure 15.2.1 <18 Age Difference Between Partners at First Sexual Intercourse, by Respondent’s Age at First Intercourse and by Residence st Age at 1 Intercourse (Years) Residence 18-19 20-24 Tbilisi Other Urban Rural 6 45 49 0 5 37 54 4 7 29 59 6 6 34 56 4 4 36 55 5 6 39 52 3 Younger <5 years older 5-10 years older >10 years older Total Figure 15.3.1 Most Commonly Cited Primary Reasons for Not Using Contraception at First Sexual Intercourse by Marital Status at First Sexual Intercourse Not Married Married 67 24 3 3 12 51 19 10 69 22 2 3 Wanted to get pregnant Did not think about using a method Sex was not expected Did not know about contraception REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 262 only 20% at ages 15-19 and only 39% at ages 20-24 used a method. These low percentages partially re- flect the desire to become pregnant, but also the lack of thought, and negligence, mentioned above. Among unmarried women only 30% of the 37 respondents in the table used a method at last sex. Of those unmar- ried women who did use contraception, almost all reported using condoms and none reported using a traditional method such as withdrawal or the calen- dar (rhythm) method. Among married young women, 25% used a modern method, with condoms (11%) and IUDs (9%) being the most common. Another 11% used a traditional method. Regarding trends over the last decade, a favorable development is that the proportion of young women not using any contraceptive method during their most recent sexual encounter has declined quite steadily, especially among unmarried women (Figure 15.3.2). It is interesting that these trends are quite similar to the results of the 2009 Adolescent RH Survey, which found that 30% of sexually active unmarried female adolescents (aged 17-19) used contraception at first intercourse (in all cases condoms, as found above) and 70% used no contraception. (Kristesashvili et al., 2009) Multiple lifetime partners were rarely reported by sexually experienced young women. In the top panel of Table 15.3.3, 98% of married young women report- ed having just one partner in the last twelve months. Among those previously married, 34% reported one and another 10% reported two or more, but over half (56%) said none. The bottom panel of the table per- tains to lifetime experience; note that the percentage distribution is for only “one” or “two or more,” unlike the top panel. So among those with any lifetime ex- perience at all, essentially 100% of married women reported only one partner, while 86% of the previ- ously married reported one and 14% or one in seven reported two or more. 15.4 Opinions and Attitudes About Condoms and Condom Use Sexually experienced young women were asked about the extent to which they agreed or disagreed with statements related to condom use (Table 15.4.1). Most respondents who had ever used condoms agreed that using condoms with a new partner is a smart idea (86%) and two-thirds (65%) agreed that women should ask their partners to use condoms. In contrast, only 57% of sexually experienced young women who had never used condoms agreed that using condoms with a new partner is a good idea, and only 19% agreed that women should ask their partners to use condoms. Far more never-users of condoms reported being uncertain about these statements (selecting “don’t know”) as opposed to agreeing or disagreeing. Interestingly, a slightly higher proportion of never-us- ers (44%) than ever-users (43%) agreed that condoms are not necessary if you know your partner; unfortu- nately both betray ignorance about the true risks of unprotected intercourse. Among all sexually experienced young women, 37% reported talking to a partner about condom use (Ta- ble 15.4.2); this was much higher (81%) among ever- users of the method than among never-users (19%). Overall discussion of condom use was considerably higher among residents of Tbilisi (62%), 20 to 24 year olds (40%), and young women with university or post- graduate education (47%) than in other subgroups. In addition (not shown), the percentage was nearly uni- versal (95%) among those who relied on condom use at last sexual intercourse, suggesting that few men use the method without discussing it, and that discussion and use are mutually reinforcing. Sexually experienced young women were asked if they agreed with specific statements about their part- ner or husband wanting to use a condom. Most (69%) stated that using a condom would make them feel safe from getting pregnant (Table 15.4.3). This varied Figure 15.3.2 1999 Trends in Contraceptive Use at Last Sexual Intercourse, by Marital Status among Young Adult Women Aged 15–24 Years Married Unmarried No method Modern Method Traditional Method 2005 2010 1999 2005 2010 11 17 72 10 22 68 11 25 64 2 98 3 17 80 30 70 0 FINAL REPORT 263 somewhat by various characteristics: 72% of urban women would feel safe from getting pregnant com- pared to 65% of rural women. Feeling safe generally increased with educational attainment; only 57% of young women with incomplete secondary or less edu- cation reporting feeling safe, compared to 70% with complete secondary education, 73% with technicum education, and 74% with university education. This reaction was very prevalent among those who were ever-users of condoms (74%) and women who had spoken to partners about condom use (75%). Condoms, uniquely, are a method that offers dual protection against unintended pregnancy and sexu- ally transmitted infection. When asked if condom use made them feel safe from getting STDs, including HIV/ AIDS, 69% of young women agreed that it did. Again, there were disparities based on certain characteristics, with higher rates of agreement among urban women (73%), ever-users of condoms (83%), and those who had talked to a partner about using condoms (81%). Other reactions included 10% who said they would be insulted or angry, 9% who would feel suspicious that her partner might be sleeping with other women, and 16% who would feel like she had done something wrong. In summary, the high percentages for feel- ing safe from pregnancy and HIV/AIDS may suggest a slight decrease in stigma surrounding condom use (Figure 15.4.1). Young people can be exposed to a wide range of at- titudes and beliefs in relation to sex and sexuality. These sometimes appear contradictory and confus- ing. Sex education needs to include opportunities for young people to develop insights and attitudes, as it can be hard for them to act on the basis of having only information. Sex education aims to reduce the risks of potentially negative outcomes from sexual behav- ior, such as unwanted or unplanned pregnancies and infection with sexually transmitted diseases includ- ing HIV. It also aims to contribute to young people’s positive understanding of their sexuality by enhancing the quality of their relationships and their ability to make informed decisions over their lifetime. In ad- dition the skills young people develop as part of sex education are linked to more general life skills. Being able to communicate, listen, negotiate with others, ask for and identify sources of help and advice, are useful life skills that can be applied to sexual relation- ships. Sex education also helps equip young people with the skills to be able to differentiate between ac- curate and inaccurate information, and to discuss a range of moral and social issues and perspectives on sex and sexuality, including different cultural attitudes and sensitive issues like abortion and contraception. Figure 15.4.1 How Respondent Would Feel if Partner Wanted to Use a Condom; 1999, 2005 and 2010 1999 2010 2005 Safe From Getting STD/HIV/AIDS Safe From Getting Pregnant Done Something Wrong Insulted or Angry Suspicious 53 67 69 63 71 69 11 5 16 13 12 10 14 12 9 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 264 Table 15.1.1 Reported Sexual Experience of Young Women Aged 15–24 by Marital Status at Time of First Sexual Experience by Residenceby Marital Status at Time of First Sexual Experience by Residence Reproductive Health Survey: Georgia 2010 No Sexual Experience After Marriage Before Marriage Total 67 7 30 6 1 7 100 0 1 960 Characteristic Reported Sexual Experience Total No. of Cases Total 67.7 30.6 1.7 100.0 1,960 15–19 88.5 10.6 0.8 100.0 861 20–24 47.8 49.6 2.6 100.0 1,099 Urban Total 69.8 28.3 1.9 100.0 937 15–19 91.5 7.8 0.7 100.0 391 20–24 50.6 46.5 2.9 100.0 546 Rural Total 65.1 33.2 1.6 100.0 1,023 15 19 85 3 13 6 1 0 100 0 47015–19 85.3 13.6 1.0 100.0 470 20–24 44.4 53.4 2.2 100.0 553 Table 15.1.2 Reported Sexual Experience of Young Women Aged 15–24 b M it l St t t Ti f Fi t S l E i b by Marital Status at Time of First Sexual Experience by Selected Characteristics. Reproductive Health Survey: Georgia, 2010 No Sexual Experience Marital Premarital Total 67 7 30 6 1 7 100 0 1 960 Characteristic Reported Sexual Experience Total No. of Cases Total 67.7 30.6 1.7 100.0 1,960 Residence Tbilisi 72.6 25.0 2.5 100.0 451 Other Urban 66.8 32.0 1.2 100.0 486 Rural 65.1 33.2 1.6 100.0 1,023 Age Group 15–17 95.9 3.9 0.2 100.0 481 18–19 78.8 19.5 1.7 100.0 380 20–21 58.9 39.7 1.3 100.0 388 22–24 40.8 55.8 3.4 100.0 711 Education Secondary incomplete or less 80.4 18.3 1.3 100.0 651 Secondary complete 58.0 40.4 1.6 100.0 604 Technicum 53 3 44 7 2 0 100 0 165Technicum 53.3 44.7 2.0 100.0 165 University /Postgraduate 66.3 31.3 2.4 100.0 540 Wealth Quintile Lowest 66.2 32.2 1.6 100.0 327 Second 61.2 36.6 2.2 100.0 448 Middle 69.1 29.5 1.3 100.0 433 Fourth 70.7 27.7 1.6 100.0 336 Highest 70.1 28.0 1.9 100.0 416 Ethnicity Georgian 69.6 28.9 1.5 100.0 1,688 Azeri 47.0 48.8 4.2 100.0 92 Armenian 64.0 34.0 2.0 100.0 135 Other 54.6 42.4 3.0 100.0 45 FINAL REPORT 265 Table 15.1.3 Reported Sexual Experience Among Young Women Aged 15–24 Years Before Given Ages (Life Table Estimates) by Selected Characteristics Reproductive Health Survey: Georgia, 2010 < 15 < 18 < 20 <22 < 24 Total 0.8 13.6 28.7 49.2 62.3 32.3 67.7 1,960 Residence Urban 0.5 11.3 25.1 45.5 57.7 30.2 69.8 937 Rural 1.2 16.0 32.3 52.0 65.7 34.9 65.1 1,023 Education Level Secondary incomplete or less 1.6 21.3 44.2 60.2 66.2 19.6 80.4 651 Secondary complete 0.5 17.4 37.3 59.0 74.1 42.0 58.0 604 Technicum/university 0.4 5.7 16.7 38.9 53.3 36.5 63.5 705 Socioeconomic Status Low 0.3 15.3 30.9 51.7 54.9 32.3 67.7 189 Middle 0.9 14.4 30.5 49.2 64.4 34.3 65.7 855 High 0.9 12.4 26.2 47.4 60.2 30.8 69.2 916 Wealth Quintile Lowest 1.2 15.2 37.0 53.1 69.0 33.8 66.2 327 Second 1.7 18.6 34.3 60.2 69.8 38.8 61.2 448 Middle 0.7 12.0 26.2 45.0 61.0 30.9 69.1 433 Fourth 0.6 13.2 26.3 43.0 53.7 29.3 70.7 336 Highest 0.2 9.8 23.0 43.8 56.6 29.9 70.1 416 Ethnicity Georgian 0.5 11.3 26.2 46.9 58.9 30.4 69.6 1,688 Azeri 4.7 35.9 53.7 75.0 85.4 53.0 47.0 92 Armenian 1.3 16.6 31.1 41.6 67.3 36.0 64.0 135 Other 1.6 33.3 43.4 62.7 73.5 45.4 54.6 45 Age at First Sexual Intercourse (Life Table Estimates)Characteristic No. of Cases Never Had Intercourse Ever Had Intercourse REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 266 Table 15.1.4 Reported Sexual Experience of Young Women Aged 15–24 by Marital Status at Time of First Sexual Experience by Education and Current Age. Reproductive Health Survey: Georgia, 2010 No Sexual Experience After Marriage Before Marriage Total 67.7 30.6 1.7 100.0 1,960 15–19 88.5 10.6 0.8 100.0 861 20–24 47.8 49.6 2.6 100.0 1,099 Secondary incomplete or less Total 80.4 18.3 1.3 100.0 651 15–19 91.2 8.0 0.8 100.0 507 20–24 34.0 62.7 3.3 100.0 144 Secondary Complete Total 58.0 40.4 1.6 100.0 604 15–19 81.9 17.3 0.7 100.0 254 20–24 36.6 61.0 2.4 100.0 350 Technicum Total 53.3 44.7 2.0 100.0 165 15–19 * * * * 18 20–24 48.8 48.9 2.3 100.0 147 University/Postgraduate Total 66.3 31.3 2.4 100.0 540 15–19 94.1 4.3 1.6 100.0 82 20–24 59.8 37.6 2.6 100.0 458 * Less than 25 cases Education and Age Group Reported Sexual Experience (Percentage Distribution) Total No. of Cases FINAL REPORT 267 Table 15.2.1 Age Difference between Partners at First Sexual Intercourse Among Sexually Experienced Young Women Aged 15 24Sexually Experienced Young Women Aged 15–24 Reproductive Health Survey: Georgia, 2010 Partner Younger Partner Less Than 5 Years Older Partner 5–10 Years Older Partner More Than 10 Years Older Age Difference Total No. of Cases* g Older Older Total 3.6 53.6 37.0 5.8 100.0 769 Residence Tbilisi 4.2 55.8 33.7 6.3 100.0 148 Other Urban 5.1 55.1 35.5 4.3 100.0 191 Rural 2.6 51.8 39.4 6.2 100.0 430 Age at First Sex < 18 0.4 48.7 45.3 5.6 100.0 270 18–19 4.1 53.5 37.4 5.0 100.0 233 20–24 6.4 58.5 28.6 6.6 100.0 266 Marital Status at First Sex Not Married 2.4 48.4 47.1 2.1 100.0 39Not Married 2.4 48.4 47.1 2.1 100.0 39 Married 3.7 53.9 36.5 6.0 100.0 730 * Exclude 3 women who did not report the age of the first sexual partner. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 268 Table 15.2.2 Relationship to Partner at First Sexual Intercourse Among Sexually Experienced Young Women Aged 15 24Sexually Experienced Young Women Aged 15–24 Reproductive Health Survey: Georgia, 2010 Husband Fiancé Boyfriend Other Total 94.6 2.8 2.1 0.4 100.0 772 Characteristic Relationship to Partner at First Sexual Intercourse Total No. of Cases Residence Tbilisi 91.1 3.2 5.8 0.0 100.0 148 Other Urban 96.4 1.1 2.4 0.2 100.0 193 Rural 95.4 3.6 0.2 0.8 100.0 431 Age at First Sex < 18 93.0 3.8 2.1 1.1 100.0 272 18 93.0 3.8 2.1 1.1 100.0 272 18–19 95.8 1.8 2.2 0.2 100.0 233 20–24 95.2 2.8 2.0 0.0 100.0 267 Marital Status at First Sex Not Married 0.0 52.7 39.1 8.2 100.0 40 Married 100.0 0.0 0.0 0.0 100.0 732 Education LevelEducation Level Secondary incomplete or less 93.5 4.1 1.2 1.3 100.0 167 Secondary complete 96.2 2.0 1.9 0.0 100.0 304 Technicum 95.8 4.2 0.0 0.0 100.0 88 University/Postgraduate 92.9 2.6 3.9 0.6 100.0 213 Wealth Quintile Lowest 95.1 1.4 1.6 1.8 100.0 128 Second 94.3 5.1 0.0 0.5 100.0 210 Middle 95.7 2.9 1.2 0.2 100.0 170 Fourth 94.7 1.7 3.6 0.0 100.0 118 Highest 93.6 2.1 4.2 0.0 100.0 146 Ethnicity Georgian 95.0 2.4 2.5 0.2 100.0 628g Azeri 92.2 7.8 0.0 0.0 100.0 58 Armenian 94.4 0.0 1.8 3.8 100.0 64 Other * * * * * 22 * Less than 25 cases in this category. FINAL REPORT 269 Table 15.3.1 Most Commonly Cited Primary Reasons for Not Using Contraception at First Sexual Intercourse by Marital Status at First Sexual IntercourseFirst Sexual Intercourse by Marital Status at First Sexual Intercourse Among Sexually Experienced Young Women Aged 15-24 Reproductive Health Survey: Georgia, 2010 Not Married Married Reason Total Marital Status at First Sexual Intercourse Wanted to get pregnant 66.6 12.1 69.3 Did not think about using a 23.7 50.8 22.4 Sex was not expected 2.9 19.4 2.1 Did not know about contraception 3.1 9.5 2.8 Partner was against it 1.3 0.0 1.3 Do not remember/Do not know 1.1 2.9 1.0 Respondent was against it 0 7 5 4 0 4Respondent was against it 0.7 5.4 0.4 Other 0.7 0.0 0.7 Total 100.0 100.0 100.0 No. of Cases 759 34 725 Table 15.2.3 Duration of Dating Before First Sexual Intercourse Among Sexually Experienced Young Women Aged 15–24 by Marital Status at First Intercourse Reproductive Health Survey: Georgia, 2010 Not Married Married < 1 Month 4.0 2.1 4.1 1–5 Months 20.1 3.7 21.0 6–11 Months 14.2 21.6 13.8 1 Year 24.7 32.5 24.3 2–5 Years 31.2 30.4 31.2 6+ Years 5.0 2.3 5.1 Does not remember 0.9 7.3 0.6 Total 100.0 100.0 100.0 No. of Cases 772 40 732 Total Marital Status at First Sexual IntercourseDuration of Dating Before First Sexual Intercourse REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 270 Table 15.3.2 Current Sexual Activity Status Among Young Adult Women Aged 15 24 by Current Marital Status and Age GroupAged 15–24 by Current Marital Status and Age Group Reproductive Health Survey: Georgia, 2010 Married PreviouslyMarried Never Married 15–19 20–24 Currently Sexually Active 19.3 62.6 18.8 0.1 5.8 32.3 Withi th l t th 18 5 61 0 4 2 0 1 5 6 30 9 Age Group Sexual Activity Status Total Current Marital Status Within the last month 18.5 61.0 4.2 0.1 5.6 30.9 1–3 months ago 0.8 1.6 14.6 0.0 0.2 1.4 Not Current Sexual Activity 2.1 2.1 74.2 0.0 0.7 3.5 Over 3 months ago but within last year 1.0 1.5 28.5 0.0 0.2 1.8 One year or longer 1.1 0.6 45.7 0.0 0.5 1.7 Currently Pregnant or Postpartum 10.4 34.0 7.0 0.0 4.9 15.6 Never Had Intercourse 67.7 0.0 0.0 99.7 88.5 47.8 No Response 0.5 1.3 0.0 0.1 0.2 0.8p Total 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,960 734 35 1,191 861 1,099 Table 15.3.3 Use of Contraception at Most Recent Sexual Intercourse by Current Marital Status and Age Group by Current Marital Status and Age Group Among Sexually Experienced Young Women Aged 15–24 Reproductive Health Survey: Georgia, 2010 15–19 20–24 All Young WomenContraceptive Method Not Currently Married or in UnionTotal Age Group Currently Married or in Union Use of Contraception at the Most Recent Sexual Encounter 35.6 36.0 19.7 39.4 29.8 Modern Methods 25.5 25.2 15.5 27.2 29.8 Oral Contraceptives 3.9 4.2 3.7 4.3 0.0 IUD 8.0 8.5 3.9 9.5 1.0 Condoms 12.2 11.0 7.3 11.8 28.8 Spermicides 1 1 1 2 0 7 1 3 0 0Spermicides 1.1 1.2 0.7 1.3 0.0 Tubal ligation 0.3 0.3 0.0 0.4 0.0 Traditional Methods 10.0 10.7 4.2 12.1 0.0 Calendar (rhythm) Method 3.1 3.3 1.5 3.7 0.0 Withdrawal 6.9 7.4 2.6 8.4 0.0 Unknown Methods 0.1 0.1 0.0 0.2 0.0U o et ods 0 0 0 0 0 0 0 Did Not Use 64.4 64.0 80.3 60.6 70.2 Total 100.0 100.0 100.0 100.0 100.0 No. of Cases* 771 734 124 610 37 * Excludes 1 woman whose most recent sexual intercourse was forced. FINAL REPORT 271 Table 15.3.4 Number of Sexual Partners Reported in the Last Twelve Months and During Lifetime by Current Marital Status Reported by Sexually Experienced Young Women Aged 15–24 Reproductive Health Survey: Georgia, 2010 Married PreviouslyMarried Never Married In the Last Twelve Months None 5.2 1.5 56.1 * One 93.2 97.7 33.7 * Two or more 1.6 0.8 10.2 * Total 100.0 100.0 100.0 * Lifetime * One 98.2 99.5 86.1 * Two or more 1.8 0.5 13.9 * Total 100.0 100.0 100.0 * No. of Cases 772 734 35 3 * Less than 25 cases in this category. Marital Status Number of Sexual Partners Total Table 15.4.1 Beliefs About Condoms and Condom Use by Condom Experience Among Sexually Experienced Women Aged 15–24 Reproductive Health Survey: Georgia, 2010 Agree Disagree Don't Know Refused Agree Disagree Don't Know Refused Using condom with a new partner is a smart idea 86.1 5.3 6.7 1.9 56.6 11.3 28.7 3.4 Women should ask their partners to use condoms 65.1 26.2 6.8 1.9 19.1 44.3 32.4 4.1 It is easy to discuss using a condom with a prospective partner 46.5 37.8 13.3 2.3 13.4 42.8 39.2 4.5 Using condoms is not necessary if you know your partner 43.2 49.8 5.1 1.9 43.7 23.4 29.4 3.5 Condoms diminish sexual enjoyment 41.4 43.9 10.1 4.5 10.6 6.2 78.4 4.8 It is embarrassing to ask for condoms in FP clinics or pharmacies 13.2 80.1 4.9 1.9 15.0 56.6 24.4 4.0 People who use condoms sleep around a lot 1.5 89.4 7.2 1.9 5.1 69.3 21.5 4.1 Same condom can be used more than once 0.5 93.2 4.4 1.9 2.0 80.4 13.6 4.0 Ever Users (N=216) Belief Never Users (N=556) REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 272 Table 15.4.2 Percentage of Women Who Have Ever Talked to a Partner About His Using Condoms by Condom Experience About His Using Condoms by Condom Experience Among Sexually Experienced Women Aged 15–24 Reproductive Health Survey: Georgia, 2010 % N % N % N Women Who Have Never Used Condoms All Sexually Experienced Women Women Who Have Ever Used CondomsCharacteristics % N % N % N Total 37.0 772 81.1 216 19.4 556 Residence Tbilisi 61.6 148 91.5 75 32.3 73 Other Urban 39.4 193 74.4 59 25.4 134 Rural 24.1 431 73.5 82 12.8 349 Age Group 15–19 23.0 130 * 23 7.4 107 20–24 39.9 642 81.1 193 22.2 449 Education Level Secondary incomplete or less 24.1 167 77.1 33 11.7 134 Secondary complete 33.8 304 74.2 68 20.9 236 Technicum/university 46.9 301 86.6 115 22.7 186 * Less than 25 cases in this category. Table 15.4.3 Percentage of Sexually Experienced Young Women Aged 15–24 Who Agreed with Specific Statements Regarding Their Feelings If a Partner/Husband Would Suggest Using Condoms Reproductive Health Survey: Georgia, 2010 Characteristic Would Feel Safe From Getting STD/HIV/AIDS Would Feel Safe From Getting Pregnant Would Feel Like I had Done Something Wrong Would Feel Insulted or Angry Would Be Suspicious That He May Sleep Around No. of Cases Total 69.1 68.7 15.8 9.5 9.4 772 Residence Urban 73.2 72.1 19.8 11.8 10.8 341 Rural 65.1 65.2 11.9 7.2 8.0 431 Residence Tbilisi 78.9 75.3 23.7 10.5 5.3 148 Other Urban 67.9 69.3 16.3 12.9 15.8 193 Rural 65.1 65.2 11.9 7.2 8.0 431 Age Group 15–19 68.7 68.6 8.9 10.0 11.1 130 20–24 69.2 68.7 17.3 9.4 9.0 642 Marital Status Currently married or in union 69.1 68.6 15.9 9.7 9.5 734 Not currently married or in union 69.4 69.1 14.2 6.3 7.9 38 Education Level Secondary incomplete or less 55.8 57.3 11.5 6.3 8.4 167 Secondary complete 69.6 70.1 16.1 12.5 10.4 304 Technicum 68.9 72.6 17.3 10.5 3.4 88 University/Postgraduate 78.2 73.5 18.1 7.4 10.9 213 Condom Use Ever users 83.2 73.9 17.1 4.5 4.2 216 Never users 63.5 66.6 15.3 11.5 11.5 556 Ever Talked to a Partner about Using Condoms Yes 80.7 74.5 18.6 5.0 4.5 282 No 62.3 65.2 14.2 12.2 12.2 490 273 CHAPTER 16 SEXUALLY TRANSMITTED INFECTIONS OTHER THAN HIV/AIDS According to 2005 WHO estimates, 448 million new cases of curable sexually transmitted infections occur annually worldwide in adults aged 15-49. Women suf- fer more frequent and severe long-term consequenc- es from STIs than men: chlamydial and gonococcal in- fections are important causes of pelvic inflammatory disease, ectopic pregnancy, and infertility, while hu- man papilloma virus (HPV) is associated with cervical cancer. An STI during pregnancy can lead to premature rupture of membranes, premature labor, and post- partum endometritis. It is estimated that in pregnant women with untreated early syphilis, 25% of pregnan- cies result in stillbirth and 14% in neonatal death - an overall perinatal mortality of about 40% (WHO, 2010). Untreated gonococcal and chlamydial infections in women will result in pelvic inflammatory disease in up to 40% of cases. One in four of these will result in infertility (WHO, 2006). In addition, STIs increase the susceptibility to and the spread of HIV infection. 16.1 STIs in Georgia and Former Soviet Countries In developing countries, STIs and their complications are one of the most important public health issues. Social and economic disruption is often followed by a substantial increase in adverse health conditions, especially infectious diseases including STIs. During the past 20 years, many former Soviet countries ex- perienced major epidemics of STIs, particularly syphi- lis. The reported incidence of new cases of syphilis increased dramatically from 1990 to1998 in Kazakh- stan, Kyrgyzstan, Belarus, and the Russian Federation (Figure 16.1.1) (WHO, 2010). Georgia has the highest syphilis incidence rates among Caucasus countries (Figure 16.1.2). A rapid increase in the reported syphi- lis rate occurred in 1995-1998 and 2000-2002 in Geor- gia. The gonorrhea incidence rate reached a peak of around 30 new cases per 100,000 several times – in 1998, 2002 and 2006 (Figure 16.1.3) (WHO, 2010). Rates of sexually transmitted infections are largely de- termined by four elements: the awareness, accessibil- ity, acceptability, and effectiveness for early diagnosis and treatment of these diseases. The previous (1999 and 2005) and current (2010) Reproductive Health Surveys conducted in Georgia were designed to help determine the awareness, self-perceived risk, preva- lence of testing, experience of symptoms, and treat- ment of STIs in a representative sample of sexually ac- tive women of reproductive age. That helps to identify the population subgroups with the greatest need of intervention, and to facilitate STI prevention and man- agement policy recommendations. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 274 16.2 Awareness of STIs Table 16.2 displays the percentage of respondents who reported that they had ever heard of the most common STIs in Georgia. Eighty-eight percent of all respondents had heard of at least one STI. Awareness of STIs varied substantially by respondent characteris- tics. Awareness of at least one STI was highest in the urban areas of the country (92%), among ages 25-44 (over 93%), in the top wealth quintiles (91%-94%), at high education levels (96%), and among women with sexual experience (94%). The majority of women in Tbilisi (93%), Shida Kartli (91%), and Mtskheta-Mtian- eti (93%) had heard of at least one STI (Figure 16.2.1). The lowest levels of awareness were found among women living in Samtskhe Javakheti (77%) and Kvemo Kartli (78%), and among Azeri women (55%). Knowledge of yeast infection ranked highest, at 88% aware, among the specific topics in Table 16.2, and syphilis ranked next, at 62%. However awareness of trichomoniasis, gonorrhea and chlamydia infections was poor: only 37% to 44% of respondents had ever heard about those diseases. The condition of least awareness was genital herpes (28%). Generally, urban residence, older age, higher educational attainment, upper wealth quintiles, and sexual experience were associated with higher levels of awareness of the se- lected STIs. From 2005 to 2010 awareness increased slightly for three STIs, namely yeast infection, chlamydia and gen- ital herpes (Figure 16.2.2). Actual declines occurred for the awareness of syphilis, trichomoniasis and gon- orrhea between the two surveys. 16.3 Awareness of Symptoms Associated with STIs The 2010 survey also assessed the awareness of par- ticular STI symptoms. Respondents who were aware of at least one STI were asked to cite spontaneously the symptoms that a woman with an STI might pre- sent. The degree of awareness was calculated accord- ing to a score that was based on the number of correct Syphilis Incidence per 100,000 Population in Eastern Europe and Central Asia:1980-2008 Figure 16.1.1 Syphilis Incidence per 100,000 Population in Caucasus Countries:1990 -2008 Figure 16.1.2 FINAL REPORT 275 STI symptoms listed by the respondent. Knowledge of a specific correct symptom was scored with +1, while the lack of it was scored with 0. Total scores ranged from 0 to 10 or higher. About 20% of women were unable to list any symptom and were scored as completely unaware of STI symp- toms. The majority of respondents mentioned one or two symptoms (25% and 26%, respectively). Only 11% of women cited four and more symptoms (Figure 16.3). More rural women than urban women failed to name any symptoms (24% vs. 16%) (Table 16.3.1). Awareness of STI symptoms increased in parallel with age, educational attainment and wealth quintile. Azeri and Armenian women were least able to list any STI symptoms. Sexually inexperienced women were less aware of STI symptoms than experienced women (32% vs. 13%). Table 16.3.2 shows that the most commonly men- tioned symptoms were vaginal discharge (55%), geni- tal itching (34%), foul smelling discharge (32%), and abdominal pain (25%). On the other hand, the least mentioned symptoms included genital sores, ulcers or warts (5%), swelling in the genital area (4%), and weight loss (1%). In general, awareness of specific STI symptoms increased with age, educational attain- ment, and wealth quintile. 16.4 Self-Perceived Risk of Contracting an STI Perception of risk of acquiring an STI is an important marker of a population’s awareness about the basic risk factors and the ways to prevent these diseases. Respondents who were aware of at least one STI symp- tom were asked to rate their own risk of contracting an STI. The majority of Georgian women (55%) consider themselves at no risk at all; about 38% perceive that they are at low risk, and another 3% believe that their risk is moderate (Table 16.4). The perception of being at some risk of an STI acquisition was highest among women living in Tbilisi, Adjara, and Samegrelo regions (Figure 16.4). More urban women consider them- selves at risk of a STI than rural women do. Generally, the self perception of a STI risk increases with higher educational attainment and upper wealth quintiles. 16.5 Self-Reported STI Testing Women with sexual experience were asked if they were ever tested for each of several STIs. Overall, 29% of sexually experienced respondents reported being Awareness of at Least one STI Among Women Aged 15-44, by Region Figure 16.2.1 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 100 90 80 70 60 50 40 30 20 10 0 80.7 93.1 91.5 78.4 77 90.1 88.4 87.9 89.6 93 86.7 P e r c e n t a g e o f W o m e n Syphilis and Gonorrhea Infections Newly Diagnosed per 100,000 Population in Georgia:1995-2008 Figure 16.1.3 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 276 tested for at least one STI not including HIV/AIDS (Ta- ble 16.5.1). Testing for at least one STI was higher in urban than in rural areas (35% vs. 24%). The highest proportion of women tested for at least one STI was reported in Tbilisi (42%), followed by Adjara (30%) and Mtskheta-Tianeti (29%) regions (Figure 16.5.1). In general, women aged 30-44 years, with high educa- tional attainment and in upper wealth quintiles, and those having two or more lifetime sexual partners were more likely to report STI testing. The most frequently tested STI was yeast infection (27%) followed by trichomoniasis (7%), chlamydiasis (3%), and genital herpes (1%). Syphilis and gonorrhea were the most rarely tested STIs. Figure 16.5.2 presents the comparison between the proportions of sexually experienced women of repro- ductive age who reported ever being tested for the se- lected STIs in the 2005 and 2010 surveys. From 2005 to 2010 self reported testing dramatically decreased for almost all selected STIs. 16.6 Self-Reported STI Symptoms All sexually active respondents were asked whether they had experienced any of the symptoms associated with STIs during the 12 months prior to the interview (Table 16.6.1). One fifth of sexually experienced wom- en reported that they had had a vaginal discharge with bad smell, 13% had itching or burning in genital area, 9% reported burning pain upon urination, 6% ex- Figure 16.2.2 100 80 60 40 20 0 Percentage of Women 2005 2010 Awareness of Selected STIs Among Women Aged 15-44; 2005 and 2010 Yeast Infection Syphilis Trichomoniasis Gonorrhea Chlamydia Genital Herpes 82 85 75 62 52 44 55 41 36 37 16 28 Infection Figure 16.3 30 25 20 15 10 5 0 Percent Awareness of STI Symptoms Among Women Aged 15-44 0 1 2 3 4 or more 20 25 26 19 11 STI Symptoms Mentioned Percent of Women Aged 15-44 Who Believe They Are at Some Risk of Contracting an STI, by Region Figure 16.4 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 60 50 40 30 20 10 0 39 48 38 37 24 50 44 48 33 32 21 P e r c e n t a g e o f W o m e n FINAL REPORT 277 perienced pain during sexual intercourse, and 3% had sores, ulcers or warts in the genital area. All of these symptoms were more common in women from rural areas than from urban areas. Symptoms diminished regularly at higher wealth quintiles. Otherwise there were only irregular differences in symptoms accord- ing to age, region, education level, wealth index, or ethnicity. More than half of women who experienced at least one of the STI symptoms in the past 12 months sought treatment. The percentage seeking treatment rose with educational attainment and wealth quintile (Ta- ble 16.6.2). The majority of respondents who sought treatment (80%) were treated by an obstetrician or gynecologist, while 15% relied on self treatment (Ta- ble 16.6.3 and Figure 16.6). Respondents who did not seek treatment for STI symptoms during the past 12 months gave a variety of reasons for not doing so (Table 16.6.4). Two thirds re- ported that they did not seek treatment because they could not afford to pay for the service or treatment. This reason was especially predominant at ages 35- 44, in rural areas, at the three lowest educational lev- els, and for the lowest wealth index. The other most common reasons for not seeking treatment were that about 12% of women declared that their symptoms disappeared over time; another 6% reported that they did not think they had an STI, and 4% feared know- ing the diagnosis. However inability to pay was the predominant reason for not seeking treatment for STI symptoms among all categories of women. Figure 16.5.2 35 30 25 20 15 10 5 0 Percentage 2005 2010 Percentage Ever Tested for STIs Among Sexually Experienced Women Aged 15-44; 2005-2010 Yeast Infection SyphilisTrichomoniasis GonorrheaChlamydia Genital Herpes 31 27 22 6 9 2 2 1 15 0.3 7 0.1 Figure 16.6 Person Who Provided STI Treatment for Sexually Experienced Women Aged 15-44 Who Sought Treatment for STI Symptoms OB/GYN 80% Self Treatment 15%Friend/Realtive 1% Other Doctor 3% Percent of Sexually Experienced Women Who Have Ever Been Tested for an STI, by Region Figure 16.5.1 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 45 40 35 30 25 20 15 10 5 0 26 42 23 25 17 30 22 27 23 29 23P e r c e n t REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 278 16.7 Primary Sources of Information on STIs Respondents who were aware of at least one STI were asked for their most important source of informa- tion about STIs, including HIV/AIDS. Television was by far the main source named (43%). It was followed by friends/colleagues (15%) and health care work- ers (14%), then next specialty books (7%) and print media (6%) (Table 16.7.1). Less than 1% of women mentioned a husband or a partner as the primary source of information. Also seldom mentioned as pri- mary sources were parents (4%), other relatives (5%), teachers (2%), and the internet (2%). However those sum to an important 14%, or one in seven women. Also it must be remembered that these are primary sources. In reality many woman are affected by multi- ple sources of information. A comparison of the 2005 and 2010 surveys shows in- creases for health care workers and parents/relatives/ partners as important sources of information. Nota- bly, mass media declined sharply as a principal source (Figure 16.7.1). Respondents were also asked if in the past 6 months they had seen, heard, or read any public announce- ment or message about STIs on television, by radio, or in newspapers. As shown in Table 16.7.2 two thirds (67%) of women reported none at all; they had not seen, heard, or read any message about STIs in these media sources. Among the rest of the women, a public announcement or a message was seen by 11% of re- spondents only on TV, was read by 3% only in newspa- pers, and was heard by less than 1% only on radio. The percentage of women reporting no exposure to either radio or TV during the past 6 months decreased by 5% between 2005 and 2010 (Figure 16.7.2). In conclusion, the surveys show the lack of aware- ness and accurate knowledge about STIs among most groups of reproductive age women in Georgia. As a result most of them underestimate their risk of ac- quiring these infections. It is important to develop and disseminate culturally appropriate information, edu- cation, and communication programs for the young, the less educated, and those living in rural areas and in the lowest wealth quintiles. Appropriately integrat- ed interventions can help prevent further spread of STI infections among these groups. Figure 16.7.1 70 60 50 40 30 20 10 0 2005 2010 Percentage Ever Tested for STIs Among Sexually Experienced Women Aged 15-44; 2005-2010 Mass Media 63 50 18 15 7 15 5 7 2 2 4 10 1 1 Friends Health Professional Books Teacher Parent, Relative, Partner Other Figure 16.7.2 80 70 60 50 40 30 20 10 0 2005 2010 Recent Exposure to Radio or TV Messages on STIs All Women Aged 15-44: 2005 and 2010 Radio/ Newspaper 0.1 0.1 4.8 4.4 1.1 0.4 0.4 0.1 8.1 11.2 3.3 3.2 1.8 1.4 72.1 66.9 Radio/TV/ Newspaper Only TV Radio/TV FINAL REPORT 279 Table 16.2 Among Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 At Least One STI % Yeast Infection % Syphilis % Trichomoniasis % Gonorrhea % Chlamydia % Genital Herpes % Total 88.0 84.8 61.8 44.1 41.4 37.4 27.7 6,292 Residence Urban 92.0 88.9 69.7 53.8 50.3 47.5 37.6 2,975 Rural 83.4 80.2 52.8 33.2 31.2 25.9 16.4 3,317 Region Kakheti 80.7 77.1 55.5 35.8 31.8 28.0 16.6 498 Tbilisi 93.1 89.4 73.7 60.2 55.0 53.9 42.7 1,426 Shida Kartli 91.5 89.9 52.5 36.7 35.9 28.2 16.0 392 Kvemo Kartli 78.4 74.4 49.4 34.6 34.1 28.6 21.3 546 Samtskhe–Javakheti 77.0 70.8 43.5 23.1 24.2 20.0 11.2 481 Adjara 90.1 86.3 56.5 46.2 37.8 36.6 32.7 419 Guria 88.4 83.8 68.4 37.8 42.4 36.4 23.2 401 Samegrelo 87.9 84.9 56.6 37.0 32.8 28.7 16.8 477 Imereti 89.6 88.6 67.8 41.7 43.2 35.3 26.7 805 Mtskheta–Mtianeti 93.0 90.9 67.3 46.8 43.2 40.5 27.8 393 Racha–Svaneti 86.7 86.1 49.7 26.6 28.2 20.1 12.8 454 Characteristic Selected STIs No. of Cases Awareness of STIs Other than HIV/AIDS by Selected Characteristics Age Group 15–19 68.6 63.7 21.5 10.8 11.1 8.1 7.5 861 20–24 84.9 81.3 50.2 31.5 30.4 28.5 22.0 1,099 25–29 93.1 90.4 67.0 47.1 42.6 40.7 30.3 1,191 30–34 95.1 92.1 77.3 56.0 50.0 47.1 33.1 1,168 35–39 94.7 92.5 80.4 59.7 57.3 50.2 36.6 1,051 40–44 94.7 92.5 82.8 68.3 64.8 56.4 41.3 922 Education Level Secondary incomplete or less 70.7 66.2 34.3 18.6 17.8 11.2 7.6 1,330 Secondary complete 87.1 83.5 53.4 34.2 29.9 28.6 18.3 1,568 Technicum 96.0 94.1 77.5 59.3 55.3 50.3 36.4 903 University/postgraduate 95.7 93.2 77.5 59.9 57.5 53.5 42.1 2,491 Wealth Quintile Lowest 79.9 75.1 47.4 25.0 23.7 19.5 11.8 1,093 Second 82.3 79.5 51.6 32.4 31.0 24.8 14.9 1,385 Middle 88.2 85.4 58.5 40.5 37.1 31.8 22.0 1,413 Fourth 91.1 88.1 67.1 49.1 47.0 42.6 32.7 1,037 Highest 94.4 91.3 76.3 63.2 58.7 57.7 47.3 1,364 Ethnicity Georgian 91.1 88.2 64.7 46.7 43.9 40.3 29.8 5,488 Azeri 54.6 50.8 25.7 13.7 13.1 7.7 3.8 276 Armenian 70.4 65.1 45.4 28.8 25.1 18.1 15.0 364 Other 84.6 79.6 67.1 48.1 46.7 34.6 27.3 164 Sexual Experience No 77.0 72.7 41.4 22.8 25.3 20.7 16.7 1,799 Yes 93.7 91.1 72.4 55.3 49.8 46.0 33.4 4,493 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 280 Table 16.3.1 Awareness of STI Symptoms Spontaneously Mentioned by Selected Characteristics Among Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 None 1 2 3 4 or More Total 19.5 25.0 25.6 18.8 11.1 100.0 6,292 Residence Urban 15.9 23.3 26.4 21.2 13.2 100.0 2,975 Rural 23.7 26.8 24.6 16.2 8.7 100.0 3,317 Region Kakheti 18.8 31.3 27.7 13.9 8.2 100.0 498 Tbilisi 13.2 20.4 27.1 23.6 15.7 100.0 1,426 Shida Kartli 18.5 22.7 25.6 20.7 12.4 100.0 392 Kvemo Kartli 25.7 29.0 22.9 16.0 6.4 100.0 546 Samtskhe–Javakheti 51.4 23.0 15.4 7.8 2.5 100.0 481 Adjara 12.3 29.1 28.4 22.0 8.2 100.0 419 Guria 9.8 44.2 23.0 16.2 6.8 100.0 401 Samegrelo 11.3 19.2 29.7 25.4 14.5 100.0 477 Imereti 25.9 26.0 24.1 12.9 11.1 100.0 805 Mtskheta–Mtianeti 26.4 23.0 23.2 17.5 9.9 100.0 393 Racha–Svaneti 25.9 22.4 21.5 19.5 10.7 100.0 454 Age Group 15–19 41.8 30.4 18.0 7.5 2.4 100.0 861 20–24 22.4 28.1 25.3 17.0 7.1 100.0 1,099 25–29 13.7 25.7 28.5 19.2 12.9 100.0 1,191 30–34 12.4 21.5 28.2 24.7 13.2 100.0 1,168 35–39 12.3 20.7 27.3 23.6 16.1 100.0 1,051 40–44 10.9 21.7 27.2 23.0 17.1 100.0 922 Education Level Secondary incomplete or less 35.7 28.6 22.1 10.1 3.5 100.0 1,330 Secondary complete 21.7 27.5 26.4 16.1 8.3 100.0 1,568 Technicum 11.6 19.5 29.8 23.2 15.9 100.0 903 University/postgraduate 11.6 23.1 25.7 24.1 15.5 100.0 2,491 Wealth Quintile Lowest 26.2 24.8 26.3 16.7 6.1 100.0 1,093 Second 26.1 26.9 24.6 16.0 6.4 100.0 1,385 Middle 19.8 27.9 24.5 16.5 11.2 100.0 1,413 Fourth 18.0 24.9 28.5 18.5 10.1 100.0 1,037 Highest 11.7 21.2 24.8 24.3 18.0 100.0 1,364 Ethnicity Georgian 16.6 24.9 26.3 20.0 12.2 100.0 5,488 Azeri 47.8 25.3 16.5 8.7 1.8 100.0 276 Armenian 42.2 21.2 22.1 11.7 2.9 100.0 364 Other 16.5 32.9 27.2 14.8 8.6 100.0 164 Sexual Experience No 31.7 29.1 22.3 11.4 5.4 100.0 1,799 Yes 13.2 22.8 27.3 22.7 14.0 100.0 4,493 Characteristic Number of Symptoms Spontaneously Mentioned Total No. of Cases FINAL REPORT 281 Table 16.3.2 Awareness of Specific STI Symptoms Spontaneously Mentioned By Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 Vaginal Discharge % Genital Itching % Foul Smelling Discharge % Abdominal Pain % Burning Pain on Urination % Redness in Genital Area % Genital Sores, Ulcers or Warts % Swelling in Genital Area % Hard to Get Pregnant % Weight Loss % Total 55.4 34.0 31.9 25.2 13.5 7.1 4.7 4.0 8.2 1.3 6,292 Residence Urban 60.6 36.0 37.1 26.1 15.5 8.8 5.2 4.8 7.1 1.5 2,975 Rural 49.5 31.6 26.1 24.1 11.3 5.1 4.2 2.9 9.3 1.0 3,317 Region Kakheti 43.0 27.7 25.0 26.7 9.5 5.7 5.4 2.8 20.3 0.3 498 Tbilisi 65.5 38.5 40.3 27.3 20.0 9.8 6.3 5.8 6.3 2.3 1,426 Shida Kartli 59.2 46.7 31.0 24.3 13.2 6.5 2.8 3.6 3.4 0.8 392 Kvemo Kartli 48.7 25.3 23.0 27.6 7.6 6.9 3.3 3.7 7.9 1.0 546 Samtskhe–Javakheti 35.6 19.6 12.6 13.4 2.0 0.5 0.6 0.2 3.9 0.0 481 Adjara 61.6 29.1 40.5 26.6 11.9 5.5 3.7 3.2 7.1 0.9 419 Guria 63.2 25.8 28.2 25.8 8.8 3.2 2.8 1.0 9.0 0.4 401 Samegrelo 59.2 41.2 32.3 36.5 18.7 10.8 5.7 4.7 9.6 2.2 477 Imereti 47.7 36.3 29.4 16.6 11.3 5.4 5.5 3.4 9.0 0.5 805 Mtskheta–Mtianeti 51.0 26.8 32.3 21.7 15.6 5.7 3.2 4.2 4.6 1.7 393 Racha–Svaneti 48.8 39.8 26.1 27.0 13.1 7.8 3.7 4.4 3.7 1.6 454 Age Group 15–19 29.2 17.4 11.4 23.3 5.3 2.5 1.8 1.2 6.2 0.9 861 20–24 52.3 28.5 28.1 24.3 10.6 5.7 3.8 2.9 6.5 0.7 1,099 25–34 60.9 39.1 36.7 25.5 15.9 8.6 5.3 4.6 8.6 1.4 2,359 35–44 66.8 41.5 41.3 26.5 17.7 8.9 6.3 5.5 9.8 1.6 1,973 Education Level Secondary incomplete or less 37.8 20.8 17.8 23.0 7.0 2.6 1.6 1.5 6.9 0.8 1,330 Secondary complete 49.9 30.4 28.9 24.5 11.6 5.8 3.8 3.0 8.7 0.9 1,568 Technicum 64.5 42.2 40.8 29.7 16.2 8.4 6.3 4.3 8.1 0.9 903 University/postgraduate 65.8 41.0 39.0 25.3 17.6 10.0 6.5 5.8 8.5 1.8 2,491 Wealth Quintile Lowest 47.9 25.9 24.1 25.0 12.0 4.0 3.7 2.4 9.1 1.0 1,093 Second 46.6 30.4 24.7 22.5 9.7 4.6 3.0 2.0 8.2 0.8 1,385 Middle 52.9 37.0 31.1 23.8 10.3 6.9 3.8 3.7 8.5 0.7 1,413 Fourth 56.6 29.1 34.2 25.8 13.3 7.4 5.7 3.7 7.7 1.3 1,037 Highest 67.3 42.1 40.8 28.0 20.2 10.6 6.6 6.6 7.6 2.2 1,364 Ethnicity Georgian 57.7 36.3 34.2 25.4 14.6 7.8 5.1 4.3 8.3 1.4 5,488 Azeri 32.5 13.3 11.8 19.8 3.9 2.2 1.7 1.1 5.8 0.0 276 Armenian 36.9 17.0 19.6 24.8 5.2 1.4 2.1 0.9 7.8 0.3 364 Other 58.1 31.6 21.3 27.9 13.7 4.8 2.1 2.4 9.0 2.1 164 Sexual Experience No 39.7 23.5 19.8 24.9 8.2 4.7 3.0 2.0 6.7 1.2 1,799 Yes 63.5 39.4 38.2 25.3 16.3 8.3 5.6 4.9 8.9 1.3 4,493 Characteristic Symptoms No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 282 Table 16.4 Self–Perceived Risk of Contracting an STI by Selected Characteristics Among Women Aged 15–44 Who Are Aware of at Least One Type of STI Reproductive Health Survey: Georgia, 2010 High Risk ModerateRisk Low Risk No Risk at All Doesn't Know Total 0.3 3.2 38.1 54.8 3.6 100.0 5,626 Residence Urban 0.4 3.6 42.5 50.5 3.0 100.0 2,777 Rural 0.3 2.6 32.6 60.2 4.3 100.0 2,849 Region Kakheti 0.4 3.1 35.7 50.6 10.2 100.0 413 Tbilisi 0.5 4.6 43.0 50.0 1.9 100.0 1,347 Shida Kartli 0.6 3.9 34.3 59.7 1.5 100.0 363 Kvemo Kartli 0.4 2.9 35.0 54.5 7.3 100.0 437 Samtskhe–Javakheti 0.2 2.0 21.6 66.5 9.7 100.0 386 Adjara 0.2 1.6 48.1 48.9 1.2 100.0 387 Guria 0.0 3.2 41.2 54.5 1.1 100.0 362 Samegrelo 0.2 1.7 45.9 50.7 1.5 100.0 429 Imereti 0.2 2.5 30.6 63.1 3.6 100.0 739 Mtskheta–Mtianeti 0.6 3.7 27.4 66.1 2.2 100.0 366 Racha–Svaneti 0.2 2.5 18.2 77.9 1.2 100.0 397 Age Group 15–19 0.2 1.6 25.1 68.3 4.8 100.0 592 20–24 0.2 3.3 36.6 56.1 3.8 100.0 946 25–29 0.0 3.5 40.5 53.2 2.8 100.0 1,103 30–34 0.8 4.2 43.4 47.7 4.0 100.0 1,111 35–39 0.6 3.9 40.4 51.0 4.2 100.0 997 40–44 0.3 2.1 40.3 55.4 2.0 100.0 877 Education Level Secondary incomplete or less 0.5 2.2 27.3 62.5 7.4 100.0 978 Secondary complete 0.0 3.2 35.0 57.3 4.5 100.0 1,391 Technicum 0.1 3.0 39.6 53.6 3.7 100.0 870 University/postgraduate 0.5 3.6 43.9 50.6 1.4 100.0 2,387 Wealth Quintile Lowest 0.2 3.3 30.0 61.6 4.9 100.0 908 Second 0.2 2.4 34.4 57.7 5.2 100.0 1,185 Middle 0.3 2.4 35.2 58.5 3.6 100.0 1,266 Fourth 0.4 3.6 41.4 51.3 3.3 100.0 968 Highest 0.5 3.9 44.3 49.3 2.0 100.0 1,299 Ethnicity Georgian 0.4 3.2 39.5 54.0 2.9 100.0 5,055 Azeri 0.0 0.6 15.1 73.0 11.4 100.0 159 Armenian 0.0 2.0 27.2 60.7 10.2 100.0 271 Other 0.6 5.6 34.1 51.3 8.3 100.0 141 Characteristic Self–Perceived Risk Total No. of Cases FINAL REPORT 283 Table 16.5.1 Percentage of Sexually Experienced Women Aged 15–44 Ever Tested for Selected Sexually Transmitted Diseases (STIs), by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Yeast Infection Trichomoniasis Chlamydia Genital Herpes Syphilis Gonorrhea Total 29.2 26.9 6.5 2.5 1.4 0.3 0.1 4,493 Residence Urban 34.6 32.0 8.4 3.2 1.6 0.3 0.1 2,048 Rural 23.7 21.6 4.5 1.7 1.1 0.2 0.2 2,445 Region Kakheti 26.2 24.2 4.8 2.5 1.6 0.2 0.2 380 Tbilisi 41.8 38.7 10.0 4.8 1.8 0.3 0.1 943 Shida Kartli 23.4 20.4 3.8 1.2 0.9 0.0 0.3 285 Kvemo Kartli 25.1 22.6 4.4 1.0 1.0 0.0 0.0 420 Samtskhe–Javakheti 17.4 15.3 1.7 1.7 1.4 0.5 0.0 350 Adjara 29.7 27.7 10.7 1.8 1.3 0.0 0.0 317 Guria 22.5 21.3 3.0 0.9 1.2 0.0 0.0 290 Samegrelo 26.7 25.3 4.6 1.9 1.4 0.3 0.3 326 Imereti 23.1 20.9 4.9 1.6 1.2 0.7 0.1 586 Mtskheta–Mtianeti 29.0 26.8 6.4 2.5 0.8 0.0 0.0 292 Racha–Svaneti 22.9 20.9 5.7 0.3 0.6 0.3 0.6 304 Age Group 15–19 20.6 18.3 6.0 3.4 1.0 0.0 0.0 130 20–24 22.2 19.4 4.2 2.1 1.6 0.0 0.0 642 25–29 26.8 25.4 4.4 1.7 1.0 0.3 0.2 910 30–34 32.4 30.3 6.0 2.8 1.4 0.3 0.1 1,036 35–39 32.0 29.3 7.4 2.1 1.9 0.2 0.1 946 40–44 31.9 28.9 9.9 3.3 1.0 0.5 0.1 829 Education Level Secondary incomplete or less 19.5 17.5 3.4 0.5 0.6 0.1 0.1 802 Secondary complete 25.5 23.8 5.7 1.7 0.9 0.1 0.1 1,196 Technicum 32.8 29.6 6.9 3.2 1.4 0.6 0.0 740 University/postgraduate 34.7 32.0 8.2 3.5 2.0 0.3 0.2 1,755 Wealth Quintile Lowest 19.5 17.8 2.4 1.7 0.7 0.1 0.3 788 Second 24.5 23.0 3.8 1.4 0.4 0.0 0.1 1,032 Middle 24.4 22.4 6.9 1.2 1.1 0.4 0.1 1,018 Fourth 34.0 31.3 6.7 2.8 1.5 0.3 0.0 710 Highest 39.9 36.3 10.7 4.6 2.6 0.4 0.1 945 Ethnicity Georgian 30.7 28.2 7.1 2.7 1.5 0.3 0.1 3,859 Azeri 14.4 13.7 0.8 0.3 0.0 0.3 0.3 234 Armenian 22.2 19.5 2.6 0.8 1.6 0.2 0.0 270 Other 30.1 27.4 8.6 1.5 0.0 0.0 0.0 130 No. of Lifetime Sexual Partners 1 28.8 26.6 6.1 2.3 1.3 0.3 0.1 4,324 2 or more 40.5 34.2 16.4 5.6 2.3 0.0 0.0 161 No response * * * * * * * 8 * Less than 25 cases. Characteristic No. of Cases Had at Least One STI STI-Testing for: REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 284 Table 16.6.1 Percentage of Sexually Experienced Women Aged 15–44 Who Experienced STI Symptoms in the Past 12 Months, by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Vaginal Discharge with a Bad Smell % Itching or Burning in the Genital Area % Burning Pain on Urination % Pain During Sexual Intercourse % Sore, Ulcer or Warts in Genital Area % Total 20.4 13.2 9.3 6.2 2.6 4,493 Residence Urban 17.8 12.0 9.0 5.0 2.5 2,048 Rural 23.1 14.4 9.6 7.5 2.8 2,445 Region Kakheti 17.9 12.0 9.0 5.4 3.4 380 Tbilisi 18.0 12.0 9.6 4.7 3.0 943 Shida Kartli 28.1 16.9 9.5 7.1 1.8 285 Kvemo Kartli 21.0 12.4 9.2 5.8 2.2 420 Samtskhe–Javakheti 25.5 9.8 3.3 3.3 1.2 350 Adjara 19.3 12.4 7.4 8.1 2.0 317 Guria 15.6 7.5 10.2 7.2 0.3 290 Samegrelo 21.8 17.7 15.0 9.0 3.3 326 Imereti 19.2 14.5 8.8 6.3 2.5 586 Mtskheta–Mtianeti 29.8 14.9 10.5 8.8 5.2 292 Racha–Svaneti 22.3 13.2 10.0 8.6 4.3 304 Age Group 15–19 28.1 15.2 13.0 7.6 7.3 130 20–24 19.3 10.8 8.2 6.7 2.0 642 25–29 17.7 10.7 6.5 5.2 1.7 910 30–34 21.5 15.5 9.8 7.2 2.4 1,036 35–39 21.2 14.0 10.5 5.8 2.8 946 40–44 20.6 13.6 10.2 5.9 3.3 829 Education Level Secondary incomplete or less 22.7 16.1 10.1 7.7 3.0 802 Secondary complete 21.9 12.6 9.4 7.1 2.5 1,196 Technicum 24.1 15.2 11.7 6.9 3.3 740 University/postgraduate 16.9 11.4 7.9 4.7 2.3 1,755 Wealth Quintile Lowest 24.6 16.2 10.6 7.3 1.8 788 Second 22.0 14.0 9.7 6.8 3.0 1,032 Middle 20.3 13.1 9.6 7.3 2.5 1,018 Fourth 20.2 12.6 8.9 6.3 3.1 710 Highest 16.8 11.1 8.1 4.0 2.6 945 Ethnicity Georgian 20.6 13.2 9.8 6.7 2.8 3,859 Azeri 21.0 12.8 5.3 2.3 2.6 234 Armenian 20.0 8.7 3.6 1.6 0.5 270 Other 14.5 19.9 13.3 8.6 1.5 130 Characteristic Symptoms No. of Cases FINAL REPORT 285 Table 16.6.2 Percentage of Sexually Experienced Women Aged 15–44 Who Presented at Least One STI Symptom in the Past 12 Months and Sought Treatment, by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Characteristic Sought Treatment Did Not Seek Treatment Not Sure Total No. of Cases Total 56.5 43.2 0.3 100.0 1,220 Residence Urban 65.2 34.6 0.2 100.0 497 Rural 49.4 50.3 0.3 100.0 723 Age Group 15–19 78.7 21.3 0.0 100.0 39 20–24 69.6 29.0 1.3 100.0 153 25–29 57.0 43.0 0.0 100.0 226 30–34 53.3 46.7 0.0 100.0 305 35–39 54.1 45.6 0.4 100.0 269 40–44 50.0 50.0 0.0 100.0 228 Education Level Secondary incomplete or less 47.1 52.4 0.4 100.0 222 Secondary complete 54.1 45.6 0.3 100.0 342 Technicum 57.7 42.3 0.0 100.0 234 University/postgraduate 63.2 36.5 0.2 100.0 422 Wealth Quintile Lowest 41.6 58.0 0.4 100.0 257 Second 53.7 45.8 0.4 100.0 293 Middle 52.4 47.6 0.0 100.0 258 Fourth 64.9 34.6 0.5 100.0 184 Highest 69.6 30.4 0.0 100.0 228 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 286 Table 16.6.3 Source of STI Treatment Among Sexually Experienced Women Aged 15–44 Who Sought Treatment for Recent STI Symptoms By Selected Characteristics Reproductive Health Survey: Georgia, 2010 OB/GYN Other Doctor Friend/Relative Self Treatment Other * Total 80.4 3.2 0.7 15.0 0.6 100.0 670 Residence Tbilisi 83.3 2.6 0.5 13.5 0.0 100.0 158 Other Urban 79.7 3.1 0.9 15.6 0.7 100.0 151 Rural 79.1 3.5 0.8 15.7 1.0 100.0 361 Age Group 15–24 87.3 4.7 0.7 7.3 0.0 100.0 130 25–34 84.8 1.1 0.1 14.0 0.0 100.0 291 35–44 72.6 4.4 1.3 20.1 1.6 100.0 249 Education Level Secondary incomplete or less 69.2 5.3 0.9 22.9 1.7 100.0 106 Secondary complete 81.3 4.9 0.6 13.2 0.0 100.0 181 Technicum 79.8 3.0 0.0 16.1 1.1 100.0 129 University/postgraduate 84.9 1.1 1.1 12.5 0.4 100.0 254 Wealth Quintile Lowest 74.8 4.6 0.0 19.4 1.1 100.0 115 Second 83.5 3.6 1.0 11.8 0.0 100.0 149 Middle 75.3 3.7 1.0 18.6 1.4 100.0 134 Fourth 83.3 2.4 0.8 13.2 0.3 100.0 114 Highest 82.7 2.3 0.5 13.9 0.6 100.0 158 * Include Nurse/Midwife (1 case) and Pharmacist (2 cases). Characteristic Source of STI Treatment Total No. of Cases Table 16.6.4 Primary Reason for Not Seeking Treatment Among Sexually Experienced Women Aged 15–44 Who Experienced STI Symptoms in the Past 12 Months and Did Not Seek Treatment, by Selected Characteristics. Reproductive Health Survey: Georgia, 2010 Cannot Afford Services or Treatment Symptom(s) Disappeared Didn't Think it Was an STI Afraid of Knowing the Results Doesn't Know Where to Go for Services Services Far Away/Inaccessible Other Refused Total 67.4 11.9 5.8 4.2 2.0 1.5 5.9 1.4 100.0 550 Residence Tbilisi 65.6 17.2 0.0 4.3 6.5 2.2 3.2 1.1 100.0 83 Other Urban 57.9 16.4 4.9 9.3 1.5 1.0 8.9 0.0 100.0 105 Rural 70.6 9.0 7.7 2.6 0.9 1.4 5.8 1.9 100.0 362 Age Group 15–24 64.2 14.7 6.0 3.5 0.0 3.7 4.2 3.6 100.0 62 25–34 62.4 11.9 7.6 4.3 2.8 1.4 8.8 0.9 100.0 240 35–44 72.4 11.1 4.3 4.2 1.8 1.0 3.9 1.3 100.0 248 Education Level Secondary incomplete or less 75.8 10.3 5.2 3.7 0.3 0.1 3.9 0.8 100.0 116 Secondary complete 74.7 8.2 5.6 3.5 0.7 1.4 3.8 2.1 100.0 161 Technicum 73.4 11.4 6.1 1.1 2.2 0.8 3.9 1.2 100.0 105 University/postgraduate 49.7 17.0 6.4 7.1 4.5 3.1 10.9 1.2 100.0 168 Wealth Quintile Lowest 74.1 11.7 6.1 2.4 0.0 1.6 3.3 0.8 100.0 142 Second 68.9 9.0 12.6 0.1 1.7 1.3 4.4 1.9 100.0 144 Middle 66.3 10.9 3.3 8.1 0.8 0.0 9.1 1.5 100.0 124 Fourth 58.8 13.2 5.3 4.5 3.4 4.7 8.7 1.4 100.0 70 Highest 63.3 16.5 0.0 6.7 6.2 0.9 5.1 1.3 100.0 70 Characteristic Total No. of Cases Primary Reason for Not Seeking Treatment FINAL REPORT 287 Table 16.7.1 Primary Source of Information About STIs Among Women Aged 15–44 Who Were Aware of at Least One Type of STI, by Selected Characteristics Reproductive Health Survey: Georgia, 2010 TV Friend/Colleague Health Profes- sional Specialty Books Print Media Other Relative Mother/ Father Teacher Internet Husband/ Partner Other Doesn't Remember/ Refused Total 42.6 15.2 14.5 6.7 5.8 4.6 4.3 2.1 1.6 0.6 1.2 0.8 100.0 5,626 Residence Urban 40.3 15.6 15.5 7.2 6.8 3.5 4.2 2.5 2.6 0.5 1.0 0.4 100.0 2,777 Rural 45.5 14.7 13.4 6.0 4.6 6.0 4.3 1.6 0.4 0.7 1.4 1.2 100.0 2,849 Region Kakheti 39.4 21.6 13.5 7.6 4.3 4.7 3.7 1.6 0.6 0.4 1.2 1.4 100.0 413 Tbilisi 39.5 16.7 12.8 7.9 7.3 3.7 4.3 2.7 3.2 0.5 0.9 0.5 100.0 1,347 Shida Kartli 41.8 18.1 11.6 6.5 5.4 7.8 3.2 1.5 0.4 1.3 1.5 0.9 100.0 363 Kvemo Kartli 41.7 13.1 13.7 7.3 3.6 6.6 5.8 2.9 2.0 0.9 0.2 2.2 100.0 437 Samtskhe–Javakheti 76.8 3.0 3.6 3.4 4.4 2.0 0.6 1.8 0.6 0.0 2.4 1.2 100.0 386 Adjara 30.0 15.6 28.6 3.7 5.1 8.1 4.9 1.2 1.4 0.8 0.6 0.0 100.0 387 Guria 46.6 10.4 17.6 5.2 5.0 4.5 6.3 0.5 0.7 1.1 1.4 0.7 100.0 362 Samegrelo 34.6 16.1 14.7 8.0 4.4 5.9 9.2 1.0 1.0 1.9 2.5 0.8 100.0 429 Imereti 51.4 13.1 13.3 6.5 7.4 1.5 1.8 2.4 0.8 0.0 1.2 0.6 100.0 739 Mtskheta–Mtianeti 45.6 14.1 16.2 4.7 5.7 5.7 2.9 3.5 0.0 0.2 1.4 0.0 100.0 366 Racha–Svaneti 59.8 13.5 11.1 3.9 2.7 3.9 3.5 0.6 0.0 0.0 0.2 0.8 100.0 397 Age Group 15–19 42.4 18.3 4.4 4.2 3.4 4.2 12.6 5.5 3.0 0.5 0.7 0.9 100.0 592 20–24 38.6 17.3 12.5 7.2 6.1 6.4 4.4 3.3 2.5 0.5 0.9 0.4 100.0 946 25–29 43.1 15.3 16.8 4.5 6.4 5.2 3.0 1.1 1.3 1.2 1.4 0.8 100.0 1,103 30–34 44.9 12.4 19.4 5.1 6.2 4.3 2.2 1.7 1.2 0.7 1.0 0.8 100.0 1,111 35–39 43.1 14.6 17.0 7.7 6.5 3.7 2.8 1.1 0.9 0.5 0.9 1.1 100.0 997 40–44 43.9 13.6 15.4 11.4 6.0 3.8 1.8 0.4 0.9 0.3 1.9 0.6 100.0 877 Education Level Secondary incomplete or less 47.8 16.2 8.7 2.2 2.7 6.9 8.2 2.2 1.2 0.9 0.9 2.1 100.0 978 Secondary complete 40.5 17.6 16.9 3.6 4.8 7.3 4.3 1.5 0.5 1.0 1.4 0.6 100.0 1,391 Technicum 45.6 13.4 16.5 8.0 5.9 4.0 1.5 3.1 0.3 0.2 1.3 0.2 100.0 870 University/postgraduate 40.6 14.0 15.0 9.9 7.8 2.3 3.4 2.0 2.8 0.5 1.1 0.4 100.0 2,387 Wealth Quintile Lowest 41.8 15.7 12.1 5.2 4.7 8.8 6.4 1.2 0.1 1.0 2.0 1.0 100.0 908 Second 47.5 15.2 13.7 4.8 3.9 5.3 4.4 1.2 0.3 1.2 1.1 1.4 100.0 1,185 Middle 46.6 12.9 14.4 7.2 6.5 3.9 3.1 1.9 0.7 0.5 1.2 1.1 100.0 1,266 Fourth 39.1 17.0 15.9 5.2 6.4 4.5 5.7 2.6 2.2 0.3 0.9 0.1 100.0 968 Highest 39.2 15.5 15.4 9.2 6.8 2.8 3.0 2.9 3.5 0.5 0.9 0.4 100.0 1,299 Ethnicity Georgian 42.1 15.5 14.6 7.2 5.9 4.2 4.2 2.2 1.7 0.6 1.2 0.5 100.0 5,055 Azeri 39.5 13.7 18.3 1.0 3.7 9.1 3.1 1.1 0.0 2.2 0.0 8.1 100.0 159 Armenian 55.0 11.6 11.0 1.9 6.3 4.3 4.8 0.7 1.5 0.9 1.0 1.1 100.0 271 Other 44.9 12.0 13.2 2.3 6.7 12.9 5.9 0.6 0.0 0.0 0.9 0.7 100.0 141 Sexual Experience No 40.4 19.6 4.9 7.5 5.2 4.3 8.5 4.9 2.9 0.0 1.0 0.7 100.0 1,422 Yes 43.6 13.3 18.7 6.3 6.1 4.8 2.4 0.9 1.0 0.9 1.2 0.8 100.0 4,204 Characteristic Primary Source of Information Total No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 288 Table 16.7.2 Public Announcements on STIs Other Than HIV/AID Seen or Heard in the Past 6 Months by Selected Characteristics and by Media Source Among All Women Aged 15–44 Reproductive Health Survey: Georgia, 2010 None Radio/Newspaper TV/ Newspaper Radio/TV/ Newspaper Only Radio Only TV Radio and TV Only Newspaper Doesn't Remember Total 66.9 0.1 4.4 0.4 0.1 11.2 1.4 3.2 12.4 100.0 6,292 Residence Urban 62.2 0.1 5.3 0.5 0.1 13.1 1.8 4.3 12.6 100.0 2,975 Rural 72.2 0.0 3.3 0.2 0.0 9.1 1.0 2.0 12.1 100.0 3,317 Region Kakheti 66.6 0.2 2.1 0.3 0.0 7.9 0.8 1.4 20.7 100.0 498 Tbilisi 63.0 0.1 6.3 0.9 0.2 14.0 2.3 4.4 8.8 100.0 1,426 Shida Kartli 73.8 0.0 2.8 0.0 0.0 19.5 0.8 1.8 1.4 100.0 392 Kvemo Kartli 69.7 0.0 3.7 0.1 0.0 7.4 2.0 2.6 14.4 100.0 546 Samtskhe–Javakheti 51.9 0.2 2.3 0.2 0.0 13.5 0.2 1.6 30.3 100.0 481 Adjara 78.5 0.0 7.5 0.0 0.0 3.4 0.7 2.8 7.1 100.0 419 Guria 72.0 0.0 4.2 0.0 0.0 13.4 1.8 1.8 6.8 100.0 401 Samegrelo 74.1 0.0 1.2 0.3 0.3 8.2 2.0 2.2 11.6 100.0 477 Imereti 61.9 0.1 3.7 0.4 0.1 12.5 0.5 4.7 16.0 100.0 805 Mtskheta–Mtianeti 62.7 0.0 5.9 0.2 0.0 13.5 1.7 2.9 13.1 100.0 393 Racha–Svaneti 72.6 0.0 2.1 0.0 0.2 11.9 1.2 1.1 10.8 100.0 454 Age Group 15–19 74.6 0.0 2.3 0.1 0.0 8.2 1.7 0.8 12.2 100.0 861 20–24 68.4 0.0 3.7 0.5 0.0 9.7 1.5 3.5 12.7 100.0 1,099 25–29 65.4 0.1 3.9 0.8 0.2 12.8 1.3 2.8 12.8 100.0 1,191 30–34 64.3 0.1 4.1 0.1 0.1 12.6 1.7 3.9 13.1 100.0 1,168 35–39 65.2 0.1 5.6 0.4 0.0 11.4 1.1 4.1 12.1 100.0 1,051 40–44 61.8 0.1 7.2 0.4 0.3 13.5 1.1 4.4 11.1 100.0 922 Education Level Secondary incomplete or less 78.5 0.0 1.2 0.1 0.2 7.4 1.3 0.7 10.6 100.0 1,330 Secondary complete 69.5 0.1 3.4 0.1 0.1 9.8 1.3 1.8 13.9 100.0 1,568 Technicum 59.6 0.0 7.9 0.3 0.2 13.3 0.7 3.7 14.2 100.0 903 University/postgraduate 61.0 0.1 5.7 0.8 0.0 13.6 1.8 5.3 11.8 100.0 2,491 Wealth Quintile Lowest 79.3 0.0 1.5 0.0 0.0 7.5 0.6 1.6 9.5 100.0 1,093 Second 72.4 0.0 2.8 0.0 0.1 9.6 1.1 1.2 12.8 100.0 1,385 Middle 66.2 0.1 3.3 0.3 0.0 11.9 1.0 3.4 13.8 100.0 1,413 Fourth 65.3 0.1 4.9 0.6 0.2 11.4 2.5 2.9 12.1 100.0 1,037 Highest 57.5 0.1 7.6 0.8 0.2 13.9 1.6 5.6 12.6 100.0 1,364 Ethnicity Georgian 66.0 0.1 4.7 0.4 0.1 12.0 1.5 3.5 11.7 100.0 5,488 Azeri 85.3 0.0 1.2 0.0 0.0 4.2 0.6 0.6 8.1 100.0 276 Armenian 63.0 0.2 1.9 0.0 0.0 8.1 0.6 1.4 24.9 100.0 364 Other 67.4 0.0 4.7 0.0 0.0 6.8 1.0 3.0 17.1 100.0 164 Sexual Experience No 71.4 0.1 2.6 0.5 0.1 9.7 1.7 2.5 11.4 100.0 1,799 Yes 64.6 0.1 5.3 0.3 0.1 12.0 1.3 3.6 12.8 100.0 4,493 Characteristic Media Source Total No. of Cases 289 CHAPTER 17 HIV/AIDS According to estimates from UNAIDS, 34 million peo- ple were living with HIV at the end of 2010. From the beginning of the HIV epidemic until now more than 16 million children have lost their parents due to AIDS. In 2010 alone, 2.7 million people were newly infected and around 390,000 children were born with HIV. Ap- proximately 1.8 million AIDS related deaths occurred in the same year. Countries of Eastern Europe and Central Asia continue to have expanding HIV/AIDS epidemics. The HIV infection rate is growing faster in these countries than in any other region of the world. Injection drug use is the main route of HIV transmis- sion in these countries but sexual transmission is in- creasing, especially between drug users and their partners. 17.1 HIV/AIDS in Georgia Georgia is still considered a low HIV prevalence coun- try, with an estimated prevalence of 0.087%, but HIV incidence has been increasing steadily over the last decade. There is a risk of a rapid spread of HIV infec- tion in the future due to the high prevalence of injec- tion drug use, sexually transmitted infections (STIs), Hepatitis B and C, and increased migration to neigh- boring countries, such as Russia and Ukraine, which are now experiencing growing HIV epidemics. The major route of HIV transmission in Georgia is injection drug use (55.5%), but in recent years sexual transmis- sions significantly increased and reached 37.5% of all transmissions [Figure 17.1]. Most HIV/AIDS cases be- long to the 29-40 age group and the male population. Over a third of people living with HIV reside in the capital (Tbilisi) with another 31% in the Black Sea Cos- tal regions of Adjara and Samegrelo (data not shown). Georgia is a low prevalence country, but HIV is in- creasing, so it is important to know the level of aware- ness and correct knowledge about HIV/AIDS in differ- ent population groups, especially among women of reproductive age, and identify factors that influence misconceptions related to HIV transmission. There- fore the 2010 survey collected detailed information about awareness, source of information, and correct knowledge related to HIV/AIDS. 17.2 Awareness and Correct Knowledge of HIV/AIDS All respondents were asked if they had ever heard about HIV/AIDS. Even though the vast majority of women (96%) had heard about it, much lower per- centages knew about the detailed items in Table 17.2. The high percentage having heard of the disease did not change significantly from the 2005 survey (95%) REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 290 (Figure 17.2.1). However the percentages having heard of HIV/AIDS were low in the subgroups of rural women (93%), women living in Kvemo Kartli Region (84%), women with incomplete secondary or less ed- ucation (88%), women in the lowest wealth quintile (90%), and especially Azeri women (60%), followed by Armenian women (88%). Simple awareness of HIV/AIDS does not necessarily re- flect the level of actual knowledge about the disease. In order to better evaluate the correct level of knowl- edge those respondents who had ever heard about the disease were asked several additional questions (Table 17.2). Overall, 71% of women believed that no cure exists for HIV/AIDS an improvement from 2005 (10% less in Figure 17.2.1). Knowledge of this fact was higher in urban than in rural areas (76% vs. 65%). As in the 2005 survey, the level of knowledge about the absence of HIV/AIDS cure rose with respondent’s age, educational level, wealth index and sexual experience. Only 33% of Azeri women and 55% of Armenian wom- en knew that there is no cure for HIV/AIDS. Only 71% of respondents overall knew that HIV infec- tion can be asymptomatic. Those less likely to know about this item included women from rural areas (60%), those living in Samtskhe Javakheti (51%) and Kvemo Kartli (55%), those in the 15-19 age group (64%), those with incomplete secondary or less edu- cation (50%), in the lowest wealth quintile (53%), and especially Azeri women (18%) (Table 17.2 and Figure 17.2.2). Poor knowledge is very important, since women who are unaware about this are at risk of HIV transmission if they have sex with an otherwise healthy HIV-positive partner. As shown in Figure 17.2.1 in 2010 the level of knowledge about asymptomatic HIV infection increased by 19% compared to 2005 but it still remains low, especially in certain subgroups. As a result, informational and educational interventions aimed to improve correct knowledge about HIV/AIDS should be conducted in the general population, to- gether with special efforts in the subgroups where the level of HIV knowledge is especially low. Respondents were also asked if they knew that the transmission of HIV can be prevented. Sixty-nine per- cent of women answered that they knew this. Knowl- edge improved about the prevention of HIV transmis- sion from 2005 to 2010 (69% vs. 57%) (Figure 17.2.1). Regarding subgroup differences, knowledge was low- er in rural than in urban areas (60% vs. 77%), among women living in Samtskhe-Javakheti (46%), among Figure 17.1 HIV/AIDS Transmission Routes Among Cases Reported to the Georgian HIV Surveillance System Blood Transfusion 0.5% Heterosexual Transmission 37.5% MTCT 2.2% Homo-/Bisexual Transmission 3.5% Injecting Drugs 55.5% Awareness and Knowledge of HIV/AIDS Among Women Aged 15-44 Figure 17.2.1 0% 20% 40% 60% 80% Aware of AIDS Knows There Is No Cure Knows It Can Be Prevented Knows It Can Be Asymtomatic Knows That Drugs Exist to Prevent Mother-to-Child-Transmission 2010 2005 100% 96 95 71 81 69 57 71 52 27 15 FINAL REPORT 291 women in the 15-19 age group (58%), those with the least education (50%), and those in the lowest wealth quintile (53%). Those with no sexual experience (65%), (young and unmarried) were less aware that there are ways to prevent HIV transmission. Azeri women showed the lowest level of this knowledge (24%), fol- lowed by Armenian women (44%) (Table 17.2). The survey also assessed the knowledge of respond- ents about the existence of drugs to reduce mother to child HIV transmission (MTCT). The percentage of women who knew that such drugs exist increased from 15% in 2005 to 27% in 2010, both very low levels (Figure 17.2.1). The level of knowledge was higher in urban than in rural areas and was directly related to age, education level, and wealth index. Women living in Samtskhe-Javakheti and Azeri women were least aware about this, but all subgroups were deficient. 17.3 HIV Testing Almost half of the respondents (49%) knew of at least one place where HIV tests are provided. As shown in Figure 17.3.1 that was an increase of 7% over the 2005 figure. Knowledge of a place was higher in urban than in rural areas (57% vs. 39%) (Table 17.3.1). The pro- portion of women knowing this information was high- est in Tbilisi (62%) compared to other regions (Figure 17.3.2). Knowledge of a testing source increased with educational attainment and wealth index. Women in the 15-19 age group, those without sexual experi- ence, and Azeri women were less likely to know about a place for HIV testing. Actual testing for HIV is the next topic. The UNAIDS testing indicator for HIV is calculated as the propor- tion of all women who were tested for HIV and also re- ceived the test results, during the previous 12 months. This indicator is used for the assessment of the acces- sibility of HIV testing services in the general popula- tion, as well as the percentage of people who know their HIV status. The numerator for this indicator is the number of respondents reporting that they were tested for HIV and also received the test results during the last 12 months. The denominator is the total num- ber of surveyed respondents. The result of the calcula- tion showed that 5.0% of the reproductive age female population were tested for HIV infection and received test results in the last 12 months (Table 17.3.1). Only 19% of respondents reported that they had ever been tested for HIV and received the test results. Most of these women (71%) were tested during antenatal care. The percentage ever tested for HIV was higher among urban women (23%), especially those who live in Tbilisi (26%) (Figure 17.3.3). Ever been tested increased with educational level and wealth index. Es- sentially no sexually inexperienced women have ever been tested. The lowest rate of HIV testing was found in Azeri women (8%), followed by Armenian women (10%). Percentage of Women Who Know that HIV/AIDS Can be Asymptomatic, by Region Figure 17.2.2 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 90 80 70 60 50 40 30 20 10 0 P e r c e n t 64 85 68 55 51 60 75 73 75 71 65 Figure 17.3.1 100 80 60 40 20 0 P e r c e n t 2005 2010 Knowledge and Experience of HIV-Testing Among Women Aged 15-44 Knowledge of HIV Testing Ever Been Tested 41.9 48.6 12.6 19.0 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 292 Respondents who reported knowing where HIV test- ing can be provided were asked to state the most likely place where an individual can be tested. About one third of women (35%) mentioned an HIV center, followed by a women’s consultation clinic (22%), a city hospital (17%) and a regional hospital (10%). Other fa- cilities such as a polyclinic, blood transfusion center, primary health care center, and STI clinics were each mentioned by less than 5% of respondents (Table 17.3.2). Among women who have ever been tested for HIV, 61% received the latest test at a women’s consulta- tion clinic, and 24% were tested at state hospitals (Fig- ure 17.3.4 and Table 17.3.3). Only 4% were last tested at an HIV center and less than 2% were tested at an STI state hospital, suggesting that there still may be a stigma associated with being tested in these types of medical facilities. Women who received HIV testing during their lifetime were asked to report when the latest test was done. Nearly half (48%) were tested more than two years ago, 27% from 13 to 24 months ago, and another 26% in the past 12 months (Table 17.3.4). This was a considerable change regarding the last 12 months: its share of all tests rose from 15% in 2005 to 26% in 2010, suggesting a trend for tests to occur earlier. The distribution by time did not differ much by social and demographic characteristics, except that the share at 12 months was higher in rural areas, and it was espe- cially high among women aged 15-24 years. Percentage of Women Who Know Where HIV Testing is Provided, by Region Figure 17.3.2 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 70 60 50 40 30 20 10 0 P e r c e n t 42 62 46 39 35 38 45 50 49 49 39 Percentage of Women Who Have Ever Been Tested for HIV, by Region Figure 17.3.3 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 30 20 10 0 18 26 13 14 13 15 15 14 21 19 10 Figure 17.3.4 Location of Last HIV Test for Women Aged 15-44 Who Reported Ever Being Tested for HIV STI Govt. Hospital 1% Govt. Hospital 24% Women’s Consultation Clinic 61% HIV Center 4% Polyclinic 3% Blood Transfusion Center 2% Private Clinic 3% FINAL REPORT 293 17.4 Sources of information on HIV/AIDS All respondents were asked if, in the past six months, they have seen, heard, or read any public announce- ments or messages on television or radio or newspa- per about HIV/AIDS (Table 17.4). Television is clearly the primary source of information: forty-three per- cent of women said that they had seen an announce- ment or message about HIV/AIDS only on TV. News- papers alone were unimportant at only 2%, but the combination of TV and newspapers was reported by 18% of women. Radio was not important at all, either in combination or alone, and less than 1% had heard a message on radio only. Almost a third of women (28%) had not seen, heard, or read any message on HIV/AIDS at all via these me- dia during the previous 6 months. By subgroups the probability of not being exposed to any message was highest in rural areas (35%) and in Kvemo Kartli Region (41%), and was inversely related to education level and wealth index. Notably, 70% of Azeri women had no exposure to these media messages about HIV/AIDS Compared to 2005, the proportion of women not be- ing exposed to any message decreased from 38% to 28 % in 2010. Meanwhile the percentage exposed to televised messages increased from 2005 to 2010: from 30% to 43% for television only in Figure 17.4. 17.5 Knowledge of HIV transmission All respondents were presented with a list of common misconceptions about HIV transmission and asked to identify which ones were incorrect. The replies were classified as correctly rejecting a misconception if the answer was “no.” The percentages of women who correctly rejected the various are highlighted in Table 17.5.1. (None of the behaviors in this table have been identified scientifically as a mode of HIV transmission.) The majority of women (82%) correctly rejected the idea that HIV is transmitted through witchcraft or other supernatural forces, meaning that 18% of re- spondents either believed or were not sure whether witchcraft plays a role in HIV transmission. Shaking hands, and sharing food or utensils with an HIV car- rier, were rejected by 82% and 70% of women, re- spectively. About two thirds of respondents rejected the idea that sharing a toilet can transmit HIV, and 62% rejected kissing an HIV infected individual as the source of HIV acquisition. Only about half of women (49%) knew that HIV cannot be transmitted through mosquito bite. Few respondents (14%) correctly re- jected getting a manicure, pedicure or haircut as a transmission route for HIV, meaning that the majority of women believed it or was not sure about it. Having dental or surgical treatment was rejected only by 5% of respondents, perhaps related to distrust of sharp instruments (below). Figure 17.5.1 100 80 60 40 20 0 Percent 2005 2010 Percentage of Women Aged 15-44 Who Correctly Reject Misconceptions about HIV Transmission: 2005 and 2010 Through Supernatural Means By Shaking Hands Using Public Toilet Sharing Food, Plates, etc Through Mosquito Bites From Manicure, Pedicure or Haircut Correctly Rejected Misconception 80 82 79 82 58 68 53 62 41 70 28 51 9 14 4 5 Through Kissing Having Dental or Surgical Treatment Figure 17.4 60 40 20 0 2005 2010 Recent Exposure to Radio or TV Messages on STIs, All Women Aged 15-44; 2005 and 2010 Radio/ Newspaper 30 38 Radio/TV/ Newspaper Only TV NoneTV/ Newspaper Only Newspaper Only Radio 1 0 1 1 12 2 4 19 18 43 28 Radio, Newspapers, or TV Messages REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 294 These misconceptions of HIV transmission are more prevalent among certain subgroups of women: rural residents, those with incomplete secondary or less education and in the lowest wealth quintile, as well as those of Azeri ethnicity. Compared to 2005, the pro- portion of respondents who correctly rejected mis- conceptions improved for all items but especially for the following misconceptions: HIV can be transmitted through sharing food and utensils, using a common toilet, kissing, and mosquito bites. Unfortunately two misconceptions, acquiring HIV infection through get- ting a manicure, pedicure or haircut and from dental or surgical procedures, still remain prevalent in 2010 (Figure 17.5.1). This may be partly due to the influence of correct knowledge, namely that HIV can indeed be transmitted via contaminated sharp objects, and may be related to the widespread distrust of the general public about the sterilization procedures conducted at health care facilities and beauty salons. Another area of interest in the survey was the level of knowledge about mother to-child HIV transmission (MTCT). Respondents were asked to name all possi- ble means of HIV transmission from an HIV-infected mother to her child. As shown in Table 17.5.2 about half of the women (49%) knew about all three of the ways shown, including 51% of urban women and 46% of rural women. Knowledge of all MTCT mechanisms was highest in Guria (72%), followed by Adjara (66%), Shida Kartli (56%), Samegrelo (49%), Tbilisi (48%) and Imereti (48%) (Figure 17.5.2). Knowledge of all three modes increased generally with age, education level, and wealth index. Women with sexual experience also had more knowledge about MTCT. Armenian women were least likely to know about all three mechanisms. Focusing on the individual modes of MTCT, fewer re- spondents knew that HIV can be transmitted from mother to child through breastfeeding (53%), com- pared to during pregnancy (75%) and during delivery (67%). In 2010 the overall knowledge about MTCT was similar to 2005; however the knowledge of HIV transmission risk from breastfeeding rose slightly by 3% (Figure 17.5.3). 17.6 Knowledge of HIV prevention Respondents were asked if they believe that measures exist to reduce the risk of contracting HIV infection. As Table 17.6.1 shows, over two thirds of all women (69%) believed that a person can do something to re- duce the risk of acquiring HIV. Ten percent did not be- lieve that such measures exist, and 21% did not know. The percent believing in the existence of some meas- ures was highest in urban areas, in older age groups, in higher education groups and at higher wealth lev- els. Lower percents occurred among rural respond- ents, women in the 15-19 age group, women with the least education and in the lowest wealth groups, also Azeri women. Percentage of Women Aged 15-44 Who Have Correct Knowledge of MTCT, by Region Figure 17.5.2 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 80 70 60 50 40 30 20 10 0 P e r c e n t 45 48 56 45 21 65 72 49 48 42 44 Figure 17.5.3 100 80 60 40 20 0 P e r c e n t 2005 2010 Percentage of Women Aged 15-44 Who Have Correct Knowledge of MTCT: 2005 and 2010 Through Breast Milk 74.2 74.7 65.5 67.4 50.4 53.1 During DeliveryDuring Pregnancy Knowledge of MTCT FINAL REPORT 295 Note however that if the “don’t know” percentage is high, the other two percentages must be depressed. Thus 30.4% of rural women said “don’t know” and if they are removed the ratio between the sizes of the other two percentages change. Instead of 59.6% and 10.0% the adjusted percentages are 85.6% “yes” and 14.4% “no” instead of 59.6% and 10.0%. That means that among those with an opinion, by far believe that helpful measures to exist. This kind of adjustment is important for all subgroups with high “don’t know” percentages. To inquire further about knowledge about HIV pre- vention, respondents were asked ways by which a person can reduce the risk of HIV infection. Thirty one percent of all women were unable to spontaneously mention any means of HIV prevention. Such respond- ents predominated in rural areas, in the Samtskhe-Ja- vakheti region, in the 15-19 age group, lowest educa- tion and wealth groups, and among women with no sexual experience, and among Azeri women. About 16% of respondents spontaneously mentioned three ways of reducing the risk of HIV contraction, while 18% cited four and 34% listed five or more ways. Overall, the mean number of correct methods of HIV preven- tion was 3.3. Women living in urban areas and those with higher educational attainment and wealth index named had higher averages (Table 17.6.2). About half of the women (51%) spontaneously men- tioned “use condoms” as a means of HIV prevention (Table 17.6.3). Many more respondents named this strategy in 2010 than in 2005 (35%) (Figure 17.6.1). “Having only one partner” was mentioned as a pre- ventive measure against HIV by 31% of women, down somewhat from 2005. “Abstinence form sexual inter- course” and “not sharing razors, blades, needles and syringes” were named by 20% of respondents, fol- lowed by “avoiding blood transfusion” (16%), “avoid- ing sex with prostitutes” (14%) and “avoiding injec- tions” (13%). In order to calculate an HIV prevention composite indi- cator, all respondents were asked prompted questions about three basic measures of HIV sexual transmission prevention: “always use condoms,” “being faithful to one uninfected partner who has no other partner,” and “abstaining from sexual intercourse.” Women were asked to agree or not with these three princi- pal ways. With prompting, 71% of all women agreed with all three methods to prevent HIV sexual transmis- sion (Table 17.6.4). The knowledge of all three meth- ods was highest in urban areas, in ShidaKartli region, among women with high education and those in the highest wealth quintile. Azeri women were by far the least likely to agree with all three methods. Consider- ing the individual components of the indicator, 82% of the respondents agreed with faithful to one part- ner,” 79% agreed with “always use condoms” and 78% agreed with “abstinence from sexual contact.” 17.7 Self-perceived risk of HIV/AIDS Respondents who reported that they had ever heard of HIV/AIDS were asked to rate their own personal risk of contracting the infection. Their self-perception was assessed according to five alternatives: high risk, mod- erate risk, low risk, no risk, and don’t know. More than half (54%) considered themselves under no risk of get- ting HIV. Thirty eight percent believed that they were at low risk, and 3% thought they were at moderate risk. Feeling at high risk was reported by less than 1% of respondents (Table 17.7). In 2010 the self perceived risk of getting HIV infection remained very similar to that in the 2005 survey (Figure 17.7.1). Table 17.7 shows the self-perceived risk of HIV infec- tion for women by selected characteristics. The per- centage who perceive themselves under no risk of contracting HIV was higher among rural women, and those living in the Samtskhe-Javakheti and Racha- Svaneti regions (Figure 17.7.2), also women aged 15- 19 years, women at the two lowest education levels and three lowest wealth quintiles, and Azeri ethnicity. Figure 17.6.1 50 45 40 35 30 25 20 15 10 5 0 2005 2010 Percentage of Women Aged 15-44 Who Spontaneously Named Selected Methods of Preventing HIV Transmission; 2005 and 2010 Have only one Partner Use Condoms Avoid Sex with Prostitutes Abstain from Sexual Intercourse Ask Partner to Get Test for HIV 36 31 35 51 20 14 18 20 14 20 5 3 Do not share needles or syringes REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 296 Figure 17.7.1 70 60 50 40 30 20 10 0 2005 2010 Perceived Risk of Getting HIV/AIDS Among Women Aged 15-44; 2005 and 2010 High 0 37 39 54 6 4 0 3 3 54 Moderate Love None Does Nor Know Level of Perceived Risk Women perceiving themselves under “some” risk of HIV infection (low plus moderate risk in Table 17.7) were more numerous in urban areas including Tbilisi, in the Samegrelo and Imereti regions, at higher educa- tional levels and in the highest wealth quintile. In conclusion, the 2010 survey established that among women of childbearing age in Georgia, particular subgroups lack awareness of and correct knowledge about HIV/AIDS. These include young adults, rural residents, women with less education, and those in the lower wealth quintiles, as well as sexually inexpe- rienced and Azeri women. The survey also showed that the rate of HIV testing still remains a challenge. Moreover, the level of awareness about places where HIV testing is provided is too low. To improve knowledge about HIV/AIDS, intensive in- formation and educational campaigns are urgently needed, in particular for the special groups named above. Common misconceptions about HIV transmis- sion need to be addressed. Careful attention should be directed to educating women about their per- sonal risks of acquiring HIV infection, to help them avoid risky behavior in the future. To raise the level of knowledge and influence public behavior, information and education campaigns must be organized in mul- tiple ways: through mass-media, family doctors, and non-medical professionals trained as peer-educators. Percentage of Women Who Believe They Have Some Risk of Contracting HIV, by Region Figure 17.7.2 Kakheti Tbilisi Shida Kartli Kvemo Kartli Samtskhe- Javakheti Adjara Guria Samegrelo Imereti Mtskheta- Mtianeti Racha- Svaneti 60 50 40 30 20 10 0 P e r c e n t 40 52 42 22 40 49 45 33 32 24 40 FINAL REPORT 297 Table 17.2 Percentage of All Women Aged 15–44 Who Have Heard of HIV/AIDS and Who Have Correct Knowledge of HIV/AIDS by Selected Characteristics Reproductive Health Survey: Georgia, 2010 That No Cure Exists for HIV/AIDS That HIV Can Be Asymptomatic That Transmission of HIV Can Be Prevented That Drugs Exist to Reduce MTCT Total 95.8 71.2 70.6 69.0 27.4 6,292 Residence Urban 98.7 76.4 80.5 77.3 31.5 2,975 Rural 92.6 65.2 59.5 59.6 22.7 3,317 Region Kakheti 88.0 65.7 63.6 57.9 16.5 498 Tbilisi 99.6 77.9 84.6 78.1 31.2 1,426 Shida Kartli 99.0 80.1 67.7 76.1 29.2 392 Kvemo Kartli 83.7 59.4 54.7 53.6 20.1 546 Samtskhe–Javakheti 92.9 54.3 50.9 46.4 13.7 481 Adjara 97.7 67.5 59.5 78.3 37.7 419 Guria 99.6 80.4 75.0 62.4 20.2 401 Samegrelo 98.3 83.2 72.8 72.4 25.5 477 I ti 97 7 67 4 74 6 67 5 30 8 805 Characteristic No. of Cases Knowledge Have Heard of HIV/AIDS Imereti 97.7 67.4 74.6 67.5 30.8 805 Mtskheta–Mtianeti 98.9 68.3 70.5 70.9 29.1 393 Racha–Svaneti 98.4 67.9 64.8 67.5 27.2 454 Age Group 15–19 93.6 63.3 63.9 57.4 17.4 861 20–24 95.0 69.2 71.5 69.2 28.0 1,099 25–29 96.5 74.1 71.8 71.9 31.1 1,191 30–34 96.7 75.2 72.5 71.2 29.4 1,168 35–39 96.5 73.0 72.6 73.8 32.0 1,051 40–44 97.1 73.7 72.2 72.3 27.3 922 Education Level Secondary incomplete or less 87.7 56.6 50.0 50.4 16.1 1,330 Secondary complete 96.2 68.3 64.1 63.6 22.0 1,568 Technicum 98.5 77.4 77.6 80.4 32.5 903 University/postgraduate 99.3 79.2 84.2 79.3 35.5 2,491 Wealth Quintile Lowest 90.2 62.1 52.9 53.2 16.5 1,093 Second 91.8 63.5 57.6 59.3 21.6 1,385 Middle 96.0 70.6 69.9 68.5 26.4 1,413 Fourth 98.9 74.6 77.2 72.8 31.7 1,037 Highest 99.6 80.1 86.3 83.0 35.5 1,364 Ethnicity Georgian 98.5 74.7 75.7 73.4 29.5 5,488 Azeri 59.9 32.6 18.0 24.2 6.0 276 Armenian 88.0 54.8 45.4 43.7 14.9 364 Other 94.0 63.9 56.0 62.1 24.0 164 Sexual Experience No 95.5 69.1 70.0 64.9 23.5 1,799 Yes 96.0 72.3 71.0 71.2 29.4 4,493 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 298 Table 17.3.1 Percent of Women Knowing an HIV Test Place and Percent Tested Among All Women Aged 15–44 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Characteristic Knows at Least One Place to Get HIV Test Ever Tested for HIV and Received Results Tested and Received Results in the Past 12 Months No. of Cases Tested and Received Results During Antenatal Care No. of Cases* Total 48.6 19.0 5.0 6,292 71.3 1,099 Residence Urban 56.9 23.2 5.5 2,975 73.4 500 Rural 39.1 14.3 4.5 3,317 68.4 599 Region Kakheti 41.6 18.4 5.1 498 82.6 103 Tbilisi 62.0 26.0 5.8 1,426 73.7 241 Shida Kartli 46.2 13.2 4.1 392 57.4 64 Kvemo Kartli 39.1 14.3 3.7 546 76.0 93 Samtskhe–Javakheti 34.5 13.5 3.6 481 82.4 92 Adjara 38.0 15.5 5.0 419 55.6 82 Guria 44.6 15.4 3.4 401 71.4 55 Samegrelo 49.9 13.8 2.7 477 55.6 70 Imereti 48.5 21.1 6.7 805 74.1 153 Mtskheta–Mtianeti 49.4 19.0 6.7 393 77.6 81 Racha–Svaneti 38.5 9.8 2.3 454 68.6 65 Age Group 15–19 24.3 3.0 1.6 861 75.8 74 20–24 47.7 20.0 7.7 1,099 72.2 363 25–29 58.8 30.3 8.3 1,191 69.5 344 30–34 56.8 29.1 5.7 1,168 68.0 199 35–39 53.8 19.2 4.6 1,051 79.0 96 40–44 53.1 12.8 1.5 922 69.7 23 Education Level Secondary incomplete or less 24.8 7.6 2.1 1,330 62.2 172 Secondary complete 43.2 17.8 5.2 1,568 68.5 330 Technicum 56.7 19.1 5.6 903 66.5 154 University/postgraduate 62.8 26.3 6.4 2,491 76.1 443 Wealth Quintile Lowest 32.5 10.9 3.2 1,093 58.8 177 Second 38.1 14.5 4.5 1,385 70.5 265 Middle 44.4 16.6 4.8 1,413 70.3 252 Fourth 53.2 20.4 5.5 1,037 71.8 177 Highest 65.6 28.0 6.2 1,364 76.3 228 Ethnicity Georgian 51.5 20.2 5.3 5,488 71.5 940 Azeri 18.1 7.7 1.1 276 81.1 55 Armenian 30.6 10.2 3.0 364 67.8 73 Other 47.3 18.5 5.8 164 59.2 31 Sexual Experience No 31.7 0.8 0.1 1,799 0.0 0 Yes 57.3 28.5 7.6 4,493 71.3 1,099 * Includes only women who gave birth in the last 2 years. FINAL REPORT 299 Table 17.3.2 Percentage of Women According to Most Likely Place for HIV Testing Among Women Aged 15–44 Who Reported Knowing Where HIV-Testing Can Be Obtained Reproductive Health Survey: Georgia, 2010 HIV Center Women's Consultation Clinic City Hospital Regional Hospital Poly- clinic Blood Trans- fusion Center Primary Health Care Clinic/ center STI Clinic Other * Does Not Remem- ber Total 35.1 22.3 16.7 10.4 4.5 4.4 2.5 2.1 1.3 0.7 100.0 3,150 Residence Urban 44.1 22.0 13.2 5.0 4.6 4.2 3.1 2.2 1.2 0.4 100.0 1,770 Rural 20.3 22.9 22.6 19.2 4.3 4.7 1.5 1.8 1.5 1.2 100.0 1,380 Region Kakheti 26.2 28.1 16.0 15.2 2.7 4.6 1.5 3.0 2.7 0.0 100.0 222 Tbilisi 56.8 18.3 7.6 1.1 4.5 4.8 2.5 2.9 1.2 0.3 100.0 928 Shida Kartli 17.9 28.6 20.1 22.6 6.0 1.7 1.3 0.9 0.4 0.4 100.0 189 Kvemo Kartli 35.4 20.1 19.3 6.9 7.7 2.6 3.3 2.6 0.7 1.5 100.0 217 Samtskhe–Javakheti 14.9 22.5 25.7 22.5 5.4 4.5 2.7 0.5 0.0 1.4 100.0 188 Adjara 19.2 13.1 37.4 19.6 2.3 0.9 6.5 0.5 0.5 0.0 100.0 172 Guria 12.1 18.8 24.7 12.1 13.5 9.4 2.2 5.4 1.8 0.0 100.0 187 Samegrelo 22.6 31.6 14.1 25.9 2.4 0.7 0.0 1.7 0.7 0.3 100.0 253 Imereti 22.1 27.5 22.1 9.0 2.3 9.2 2.3 1.0 2.3 2.3 100.0 418 Mtskheta–Mtianeti 32.3 23.5 16.9 7.7 10.4 1.9 2.7 1.2 3.1 0.4 100.0 199 Racha–Svaneti 30.4 14.3 19.8 21.2 6.0 1.4 0.5 0.5 1.8 4.1 100.0 177 Age Group 15–19 37.4 9.8 16.0 11.4 10.1 4.8 3.4 5.1 0.7 1.2 100.0 219 20–24 31.5 24.6 21.4 10.7 4.7 1.7 1.8 1.3 1.4 0.9 100.0 550 25–29 29.1 30.3 18.6 10.5 3.2 2.9 2.2 0.6 1.7 1.0 100.0 694 30–34 35.9 25.9 15.2 9.9 2.4 4.9 1.8 2.2 1.0 0.7 100.0 648 35–39 37.7 21.3 13.7 8.8 5.5 4.7 3.7 2.8 1.5 0.4 100.0 571 40–44 42.1 13.5 14.4 11.6 4.0 8.2 2.6 2.0 1.2 0.3 100.0 468 Education Level Secondary incomplete 23.8 20.1 17.2 18.1 9.2 4.0 3.3 2.7 0.6 1.1 100.0 363 Secondary complete 23.8 26.5 22.9 12.2 4.7 3.0 1.9 2.6 0.9 1.6 100.0 690 Technicum 30.2 19.4 18.0 15.4 4.6 7.1 2.0 1.4 1.5 0.4 100.0 504 University/ postgraduate 44.0 22.0 13.6 6.3 3.2 4.3 2.7 1.9 1.6 0.4 100.0 1,593 Wealth Quintile Lowest 18.7 23.2 24.8 18.2 5.6 3.4 2.3 1.8 1.3 0.7 100.0 389 Second 18.7 23.4 21.1 20.2 6.2 5.1 1.1 1.2 1.1 1.9 100.0 573 Middle 21.3 24.9 21.0 17.6 4.2 3.1 2.9 2.3 1.8 0.9 100.0 662 Fourth 35.7 24.0 15.3 6.3 5.0 6.4 2.7 2.4 1.2 0.9 100.0 588 Highest 54.3 19.2 11.0 2.2 3.2 3.9 2.8 2.1 1.2 0.0 100.0 938 Ethnicity Georgian 36.3 22.0 16.5 10.1 4.4 4.3 2.3 2.2 1.3 0.6 100.0 2,908 Azeri 14.8 17.0 32.7 21.6 3.9 1.6 0.0 0.0 1.7 6.7 100.0 54 Armenian 17.2 32.1 15.6 12.7 9.9 8.1 1.9 0.0 1.9 0.5 100.0 110 Other 30.7 25.9 13.6 7.6 2.2 5.7 10.7 2.6 1.1 0.0 100.0 78 Sexual Experience No 49.6 5.3 13.9 9.2 8.7 5.7 2.5 3.7 0.6 0.9 100.0 591 Yes 31.0 27.2 17.5 10.7 3.3 4.0 2.5 1.6 1.5 0.7 100.0 2,559 * Includes 27 women who mentioned Mobile Clinics and 9 women who mentioned Family Medicine Centers. Characteristic Total No. of Cases Most Likely Place REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 300 Table 17.3.3 Percentage of Women According to Site of Their Last HIV Test Among Women Aged 15-44 Ever Tested for HIV, by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Women's Consultation Center Govt. Hospital HIV Center Polyclinic Blood Transfusion Center STI Clinic Private Clinic Family Planning Clinic Mobile Clinic Other Total 61.2 24.3 4.1 3.1 1.7 1.5 3.1 0.4 0.2 0.4 100.0 1,582 Residence Tbilisi 63.5 16.2 7.5 3.5 2.0 1.3 5.5 0.4 0.2 0.2 100.0 476 Other Urban 68.4 16.8 3.2 4.1 1.8 2.2 1.9 0.8 0.0 0.7 100.0 417 Rural 54.1 37.0 1.7 2.0 1.3 1.2 1.9 0.1 0.5 0.4 100.0 689 Age Group 15–24 62.2 27.8 2.2 1.5 1.1 2.1 3.1 0.0 0.0 0.0 100.0 361 25–34 62.6 24.8 4.2 2.4 1.0 1.1 2.6 0.7 0.2 0.5 100.0 847 35–44 57.2 20.0 5.8 6.2 3.7 1.7 4.3 0.0 0.6 0.5 100.0 374 Education Level Secondary incomplete or less 56.6 31.8 1.1 5.6 0.7 0.2 1.2 0.5 1.6 0.7 100.0 163 Secondary complete 59.6 30.0 3.4 2.6 0.6 1.2 1.6 0.0 0.1 0.8 100.0 369 Technicum 56.0 27.5 6.0 3.4 1.7 2.6 2.4 0.5 0.0 0.0 100.0 230 University/postgraduat 64.2 19.5 4.5 2.8 2.3 1.6 4.4 0.5 0.1 0.2 100.0 820 Wealth Quintile Lowest 54.1 38.8 2.1 2.9 0.0 1.6 0.3 0.0 0.2 0.0 100.0 196 Second 52.6 34.1 1.7 4.1 1.0 2.7 2.2 0.3 0.9 0.4 100.0 294 Middle 57.5 32.8 2.9 2.4 1.0 0.4 1.6 0.0 0.0 1.3 100.0 323 Fourth 66.9 18.1 5.1 1.9 4.0 1.1 2.3 0.4 0.0 0.3 100.0 295 Highest 66.1 14.3 6.0 3.7 1.6 1.7 5.6 0.7 0.2 0.0 100.0 474 Characteristic Location of the Last HIV Test Total No. of Cases Table 17.3.4 Percentage of Women According to Time Since Last HIV Test Among Women Aged 15–44 Who Have Ever Been Tested for HIV Reproductive Health Survey: Georgia, 2010 12 Months 13–24 Months More Than 2 Years Total 26.0 25.9 48.1 100.0 1,582 Residence Tbilisi 22.5 27.6 49.8 100.0 476 Other Urban 25.3 23.7 51.0 100.0 417 Rural 29.6 25.9 44.5 100.0 689 Age Group 15–24 38.6 35.2 26.2 100.0 361 25–34 23.4 26.4 50.2 100.0 847 35–44 19.0 15.6 65.4 100.0 374 Education Level Secondary incomplete or less 23.5 27.8 48.6 100.0 163 Secondary complete 30.5 28.0 41.5 100.0 369 Technicum 26.7 27.9 45.4 100.0 230 University/postgraduate 24.2 24.0 51.7 100.0 820 Wealth Quintile Lowest 25.6 28.2 46.2 100.0 196 Second 29.8 28.8 41.4 100.0 294 Middle 28.8 22.7 48.5 100.0 323 Fourth 26.1 26.4 47.5 100.0 295 Highest 22.7 25.3 52.0 100.0 474 Characteristic Time Since Last HIV Test Total No. of Cases FINAL REPORT 301 Table 17.4 Percentage of Women According to Primary Source of Information on HIV/AIDS Among All Women Aged 15–44 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 None Radio/Newspaper TV/ Newspaper Radio/TV/ Newspaper Only Radio Only TV Radio and TV Only Newspaper Does Not Remember Total 28.1 0.3 18.1 1.4 0.6 43.0 1.5 2.1 5.0 100.0 6,292 Residence Urban 22.2 0.3 22.1 2.1 0.6 43.9 2.2 2.5 4.1 100.0 2,975 Rural 34.7 0.2 13.7 0.6 0.7 41.9 0.7 1.6 6.0 100.0 3,317 Region Kakheti 32.1 0.3 8.5 1.4 0.5 39.7 1.3 2.2 13.9 100.0 498 Tbilisi 21.8 0.2 23.8 2.6 0.7 44.0 3.0 2.3 1.6 100.0 1,426 Shida Kartli 35.3 0.2 11.2 0.6 0.4 49.7 1.2 0.8 0.6 100.0 392 Kvemo Kartli 41.0 0.3 14.6 1.9 0.4 31.4 0.4 2.1 7.9 100.0 546 Samtskhe–Javakheti 23.8 0.2 9.5 0.2 1.1 51.4 0.8 1.1 12.1 100.0 481 Adjara 32.3 0.7 32.3 0.0 0.0 31.3 0.0 3.0 0.4 100.0 419 Guria 23.4 0.0 16.0 0.2 0.0 56.2 0.8 0.6 2.8 100.0 401 Samegrelo 39.7 0.0 8.7 0.7 1.0 38.8 1.5 2.4 7.2 100.0 477 Imereti 18.2 0.2 18.6 1.3 1.2 51.7 1.1 1.6 6.1 100.0 805 Mtskheta–Mtianeti 25.3 0.4 18.8 1.0 0.2 46.2 0.8 4.6 2.9 100.0 393 Racha–Svaneti 31.3 0.0 9.4 0.2 0.2 52.0 0.4 1.8 4.8 100.0 454 Age Group 15–19 29.6 0.0 11.1 1.5 0.4 47.7 1.4 2.2 5.9 100.0 861 20–24 28.7 0.1 18.1 2.1 1.5 40.5 1.5 2.2 5.4 100.0 1,099 25–29 26.7 0.3 17.1 1.9 0.9 44.8 1.4 2.3 4.6 100.0 1,191 30–34 28.0 0.2 18.9 1.1 0.6 41.1 1.5 2.5 6.1 100.0 1,168 35–39 27.2 0.6 22.3 0.4 0.3 42.6 1.2 1.6 4.0 100.0 1,051 40–44 28.0 0.4 22.7 1.2 0.1 40.6 1.8 1.7 3.6 100.0 922 Education Level Secondary incomplete or less 41.7 0.1 9.6 0.5 0.3 39.2 1.0 1.3 6.3 100.0 1,330 Secondary complete 32.4 0.2 13.0 0.8 0.8 43.9 0.7 2.1 6.0 100.0 1,568 Technicum 23.9 0.1 22.1 1.0 0.6 44.5 1.0 2.1 4.8 100.0 903 University/postgraduate 18.9 0.4 24.9 2.4 0.7 44.0 2.4 2.6 3.7 100.0 2,491 Wealth Quintile Lowest 44.9 0.0 8.1 0.1 0.4 39.1 0.8 2.2 4.5 100.0 1,093 Second 35.9 0.4 12.1 0.4 0.5 41.6 0.3 1.2 7.5 100.0 1,385 Middle 26.9 0.3 15.4 1.1 0.7 46.7 0.9 2.0 5.9 100.0 1,413 Fourth 21.1 0.3 23.0 2.2 1.2 43.8 2.0 2.8 3.7 100.0 1,037 Highest 18.6 0.2 27.2 2.6 0.5 42.5 2.7 2.3 3.5 100.0 1,364 Ethnic Group Georgian 25.1 0.3 19.7 1.6 0.7 44.6 1.6 2.1 4.2 100.0 5,488 Azeri 70.1 0.0 2.4 0.0 0.0 19.0 0.0 0.7 7.8 100.0 276 Armenian 33.7 0.2 8.4 0.3 0.5 41.7 0.3 2.2 12.7 100.0 364 Other 31.0 0.6 15.4 0.6 0.3 38.1 2.6 2.8 8.7 100.0 164 Sexual Experience No 25.9 0.2 16.6 2.1 0.7 44.4 2.0 2.7 5.3 100.0 1,799 Yes 29.2 0.3 18.9 1.0 0.6 42.2 1.2 1.7 4.8 100.0 4,493 Characteristic Source of Information Total No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 302 Table 17.5.1 Percentage of Women Rejecting Misconceptions About HIV Transmission by Selected Characteristics Among All Women Aged 15-44 Reproductive Health Survey: Georgia, 2010 Witchcraft ShakingHands Sharing Food, Plates, Etc. With Someone Who Has HIV/AIDS Sitting on a Toilet Seat After Someone Who is Infected Through Kissing Through Mosquito Bites Getting a Manicure, Pedicure or Haircut Having Dental or Surgical Treatment Total 81.6 81.6 70.2 67.6 61.8 51.0 13.8 4.9 6,292 Residence Urban 87.4 89.3 80.4 78.4 72.1 60.4 11.8 4.3 2,975 Rural 74.9 72.8 58.6 55.5 50.3 40.3 16.1 5.6 3,317 Region Kakheti 66.6 68.2 60.0 55.2 52.5 37.8 15.2 1.9 498 Tbilisi 88.8 93.6 84.3 80.3 76.7 61.6 11.4 3.1 1,426 Shida Kartli 89.7 85.4 70.4 66.3 65.9 51.9 16.6 6.1 392 Kvemo Kartli 63.9 60.0 52.0 52.0 47.1 37.3 9.0 3.6 546 Samtskhe–Javakheti 74.7 71.3 59.8 58.2 53.0 41.9 10.2 3.7 481 Adjara 84.5 80.1 65.2 68.9 46.9 60.7 25.9 12.6 419 Guria 80.2 88.4 65.4 65.8 62.6 49.4 12.0 4.6 401 Samegrelo 84.2 87.7 72.4 73.6 61.2 58.5 15.8 4.5 477 Imereti 84.0 81.2 70.3 64.3 62.7 42.3 11.4 5.1 805 Mtskheta–Mtianeti 86.9 81.9 70.2 63.9 61.4 48.1 16.2 6.8 393 Racha–Svaneti 83.5 82.4 65.0 60.2 58.6 48.3 17.1 7.8 454 Age Group 15–19 78.0 78.2 62.2 58.7 54.4 42.6 15.1 5.5 861 20–24 80.9 82.5 70.4 68.9 62.4 51.8 13.7 4.9 1,099 25–29 84.4 82.0 69.3 68.4 60.1 52.6 14.2 4.5 1,191 30–34 81.1 81.1 70.8 68.4 64.0 50.6 11.2 3.6 1,168 35–39 82.4 82.0 74.4 70.7 65.5 53.0 12.8 4.6 1,051 40–44 83.1 84.2 75.5 72.2 65.8 56.7 16.0 6.1 922 Education Level Secondary incomplete or less 66.0 63.6 50.7 48.4 41.7 34.3 15.9 5.8 1,330 Secondary complete 80.3 77.5 62.7 60.6 52.1 45.2 16.9 6.3 1,568 Technicum 87.7 86.9 78.1 75.5 65.2 55.9 15.1 6.0 903 University/postgraduate 89.2 92.7 83.4 80.5 78.4 62.5 10.2 3.1 2,491 Wealth Quintile Lowest 68.6 67.5 53.8 49.8 44.6 36.6 16.6 4.5 1,093 Second 72.4 71.5 58.0 56.3 50.5 42.1 15.9 6.3 1,385 Middle 82.9 80.6 68.0 65.3 59.1 46.4 15.7 5.3 1,413 Fourth 85.9 88.5 78.2 78.1 70.3 60.6 11.9 4.9 1,037 Highest 91.5 93.0 84.6 80.8 76.4 62.7 10.5 3.6 1,364 Ethnicity Georgian 85.6 86.0 74.4 71.8 66.2 54.0 13.8 4.9 5,488 Azeri 37.8 30.2 21.3 21.7 16.7 14.3 8.7 2.4 276 Armenian 63.1 62.9 52.6 51.6 41.0 38.3 14.1 5.1 364 Other 70.4 73.4 61.6 54.8 49.4 48.5 22.0 7.2 164 Sexual Experience No 80.8 82.4 68.0 66.1 62.3 49.2 13.4 4.7 1,799 Yes 82.0 81.2 71.3 68.4 61.6 51.9 14.1 5.0 4,493 Characteristic Misconceptions About How HIV Transmission Can Occur No. of Cases FINAL REPORT 303 Table 17.5.2 Percentage of Women Knowing How Maternal-to-Child Transmission (MTCT) Can Occur Among All Women Aged 15-44 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 During Pregnancy During Delivery DuringBreastfeeding All Three Total 74.7 67.4 53.1 48.9 6,292 Residence Urban 78.4 72.3 55.7 51.3 2,975 Rural 70.5 61.7 50.2 46.2 3,317 Region Kakheti 64.7 59.5 46.4 44.6 498 Tbilisi 78.2 72.9 53.6 48.2 1,426 Shida Kartli 86.6 76.9 60.4 56.2 392 Kvemo Kartli 63.4 56.7 48.4 45.1 546 Samtskhe–Javakheti 43.3 42.1 30.3 21.0 481 Adjara 82.9 77.8 67.5 65.5 419 Guria 88.6 80.8 74.0 72.0 401 Samegrelo 75.8 68.9 51.3 48.7 477 Imereti 79.3 64.6 53.4 48.4 805 Mtskheta–Mtianeti 73.8 64.8 46.0 42.2 393 Racha–Svaneti 73.4 63.8 49.9 44.4 454 Age Group 15–19 64.4 52.2 45.9 40.3 861 20–24 73.3 65.6 50.8 46.3 1,099 25–29 76.1 70.4 53.7 50.3 1,191 30–34 78.9 72.3 56.0 52.1 1,168 35–39 79.7 74.0 59.1 55.5 1,051 40–44 77.5 72.3 54.5 50.7 922 Education Level Secondary incomplete or less 61.3 51.6 42.4 39.2 1,330 Secondary complete 72.9 64.5 52.7 48.5 1,568 Technicum 81.7 73.1 55.1 52.2 903 University/postgraduate 81.2 76.2 58.8 53.7 2,491 Wealth Quintile Lowest 66.6 60.3 51.6 48.0 1,093 Second 69.3 61.4 50.4 46.9 1,385 Middle 75.1 65.1 50.1 45.7 1,413 Fourth 79.7 74.1 56.8 53.8 1,037 Highest 79.4 72.9 55.8 50.2 1,364 Ethnicity Georgian 78.8 71.2 55.7 51.6 5,488 Azeri 41.6 36.0 33.1 31.9 276 Armenian 42.9 39.3 32.5 23.8 364 Other 69.0 57.0 46.5 44.4 164 Sexual Experience No 69.7 59.6 49.2 44.0 1,799 Yes 77.3 71.4 55.2 51.5 4,493 Characteristic How MTCT Can Occur No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 304 Table 17.6.1 Percentage of Women Who Believe that Something Can Be Done to Reduce the Risk of Contracting HIV, Among All Women Aged 15-44 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Characteristic Yes, Can Do Something No, Cannot Do Something Does Not Know Total No. of Cases Total 69.0 9.8 21.2 100.0 6,292 Residence Urban 77.3 9.6 13.1 100.0 2,975 Rural 59.6 10.0 30.4 100.0 3,317 Region Kakheti 57.9 8.5 33.5 100.0 498 Tbilisi 78.1 10.7 11.1 100.0 1,426 Shida Kartli 76.1 10.3 13.6 100.0 392 Kvemo Kartli 53.6 10.6 35.9 100.0 546 Samtskhe–Javakheti 46.4 3.9 49.7 100.0 481 Adjara 78.3 8.7 13.0 100.0 419 Guria 62.4 23.8 13.8 100.0 401 Samegrelo 72.4 11.4 16.1 100.0 477 Imereti 67.5 7.6 24.9 100.0 805 Mtskheta–Mtianeti 70.9 7.8 21.3 100.0 393 Racha–Svaneti 67.5 12.1 20.4 100.0 454 Age Group 15–19 57.4 12.5 30.0 100.0 861 20–24 69.2 10.0 20.8 100.0 1,099 25–29 71.9 9.3 18.9 100.0 1,191 30–34 71.2 9.4 19.5 100.0 1,168 35–39 73.8 8.4 17.8 100.0 1,051 40–44 72.3 8.5 19.2 100.0 922 Education Level Secondary incomplete or less 50.4 11.6 37.9 100.0 1,330 Secondary complete 63.6 11.1 25.3 100.0 1,568 Technicum 80.4 6.6 12.9 100.0 903 University/postgraduate 79.3 8.9 11.8 100.0 2,491 Wealth Quintile Lowest 53.2 11.9 34.8 100.0 1,093 Second 59.3 9.7 31.0 100.0 1,385 Middle 68.5 9.8 21.7 100.0 1,413 Fourth 72.8 10.8 16.4 100.0 1,037 Highest 83.0 7.8 9.2 100.0 1,364 Ethnicity Georgian 73.4 9.9 16.7 100.0 5,488 Azeri 24.2 5.7 70.1 100.0 276 Armenian 43.7 10.9 45.4 100.0 364 Other 62.1 10.1 27.8 100.0 164 Sexual Experience No 64.9 11.7 23.4 100.0 1,799 Yes 71.2 8.8 20.1 100.0 4,493 FINAL REPORT 305 Table 17.6.2 Percentage of Women Who Believe that Something Can Be Done to Reduce the Risk of Contracting HIV, Among All Women Aged 15-44 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 0 1–2 3 4 5 or More Total 3.3 31.0 0.7 15.8 18.1 34.3 100.0 6,292 Residence Urban 3.8 22.7 0.5 16.1 18.8 41.9 100.0 2,975 Rural 2.7 40.4 1.0 15.5 17.4 25.8 100.0 3,317 Region Kakheti 2.6 42.1 1.6 15.5 16.8 24.1 100.0 498 Tbilisi 3.8 21.9 0.4 15.6 20.4 41.7 100.0 1,426 Shida Kartli 3.5 23.9 1.8 16.6 17.9 39.8 100.0 392 Kvemo Kartli 2.5 46.4 0.7 11.0 14.9 27.0 100.0 546 Samtskhe–Javakheti 2.0 53.6 0.2 10.9 19.4 16.0 100.0 481 Adjara 3.7 21.7 0.5 16.3 16.9 44.6 100.0 419 Guria 3.0 37.6 0.4 15.0 17.2 29.8 100.0 401 Samegrelo 3.6 27.6 0.3 12.9 18.5 40.7 100.0 477 Imereti 3.0 32.5 0.7 21.6 17.4 27.8 100.0 805 Mtskheta–Mtianeti 3.0 29.1 1.3 21.3 18.8 29.5 100.0 393 Racha–Svaneti 3.1 32.5 0.7 14.0 22.2 30.6 100.0 454 Age Group 15–19 2.5 42.6 0.8 15.5 17.7 23.4 100.0 861 20–24 3.2 30.8 0.6 18.4 18.5 31.7 100.0 1,099 25–29 3.4 28.1 0.5 14.7 18.7 38.0 100.0 1,191 30–34 3.4 28.8 1.0 16.3 18.3 35.6 100.0 1,168 35–39 3.6 26.2 0.7 14.3 16.7 42.1 100.0 1,051 40–44 3.4 27.7 0.7 15.4 19.0 37.2 100.0 922 Education Level Secondary incomplete or less 2.2 49.6 0.3 16.0 15.5 18.7 100.0 1,330 Secondary complete 2.9 36.4 1.3 15.6 16.5 30.3 100.0 1,568 Technicum 3.8 19.6 0.3 17.5 22.0 40.6 100.0 903 University/postgraduate 3.9 20.7 0.7 15.3 19.4 43.8 100.0 2,491 Wealth Quintile Lowest 2.3 46.8 1.2 16.4 15.0 20.6 100.0 1,093 Second 2.6 40.7 0.4 17.4 18.4 23.1 100.0 1,385 Middle 3.2 31.5 1.2 14.6 17.4 35.2 100.0 1,413 Fourth 3.5 27.2 0.4 15.2 17.7 39.5 100.0 1,037 Highest 4.1 17.0 0.5 15.7 20.7 46.2 100.0 1,364 Ethnicity Georgian 3.5 26.6 0.8 16.7 19.1 36.8 100.0 5,488 Azeri 1.1 75.8 0.0 6.2 7.2 10.9 100.0 276 Armenian 1.9 56.3 0.2 10.1 15.1 18.4 100.0 364 Other 2.8 37.9 0.4 17.0 14.3 30.4 100.0 164 Sexual Experience No 3.0 35.1 0.8 15.5 18.5 30.1 100.0 1,799 Yes 3.4 28.8 0.7 16.0 18.0 36.5 100.0 4,493 Characteristic Total No. of Cases Number of Measures NamedMean No. of Measures Named REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 306 Table 17.6.3 Percentage of Women Who Believe that Something Can Be Done to Reduce the Risk of Contracting HIV, Among All Women Aged 15-44 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Tbilisi OtherUrban Rural 15–19 20–24 25–29 30–34 35–39 40–44 Methods to Prevent Sexual Transmission of HIV Use condoms 50.6 61.0 58.5 40.2 39.0 52.0 56.2 53.4 52.0 51.9 Have only one partner 30.5 35.6 34.0 25.5 22.8 28.5 32.1 31.8 36.6 32.5 Abstain from sexual Intercourse 20.3 25.1 23.1 15.9 18.8 19.4 19.1 20.9 22.8 21.1 Limit number of sexual partners 10.6 13.0 12.9 7.8 5.5 10.8 12.0 10.3 14.2 11.1 Avoid sex with persons who have 3.3 3.0 4.2 3.0 1.5 3.2 3.5 3.5 4.5 3.9 Ask partner to get test for HIV 2.6 4.2 2.2 1.9 1.4 1.6 2.8 3.5 3.1 3.3 Methods to Prevent Blood Do not share razors, blades, needles 20.0 26.4 22.1 15.1 13.3 20.1 22.1 20.0 25.0 20.2 Avoid blood transfusions 15.9 20.1 18.0 12.3 12.4 14.0 17.5 17.4 17.5 17.5 Avoid injections 13.5 17.0 16.2 9.9 11.4 12.3 12.4 13.3 17.3 15.0 Methods to Prevent the Avoid sex with prostitutes 14.3 14.4 16.8 12.9 8.2 13.3 16.3 15.2 17.5 16.3 Avoid sex with persons who inject 9.3 12.8 9.9 6.8 6.0 8.7 11.5 9.7 10.2 9.9 Avoid sex with bisexuals 1.6 1.8 2.7 1.0 1.0 1.4 1.2 1.5 2.3 2.7 No. of Cases 6,292 1,426 1,549 3,317 861 1,099 1,191 1,168 1,051 922 Characteristic Total Residence Age Group FINAL REPORT 307 Table 17.6.4 Percentage of Women Who Believe that Something Can Be Done to Reduce the Risk of Contracting HIV, Among All Women Aged 15-44 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Be Faithful to One Partner Always Use Condoms Abstain From Sexual Intercourse All Three Total 82.5 78.7 78.4 70.9 6,292 Residence Urban 88.5 85.2 84.5 77.5 2,975 Rural 75.7 71.3 71.4 63.4 3,317 Region Kakheti 66.1 63.0 61.6 54.1 498 Tbilisi 89.0 88.0 83.4 77.7 1,426 Shida Kartli 94.5 88.6 91.7 83.6 392 Kvemo Kartli 66.3 58.3 63.9 54.1 546 Samtskhe–Javakheti 76.6 71.0 75.0 68.6 481 Adjara 89.9 79.4 89.0 76.7 419 Guria 80.2 81.8 87.0 70.6 401 Samegrelo 85.7 82.2 80.2 76.5 477 Imereti 81.5 80.3 74.7 68.4 805 Mtskheta–Mtianeti 85.9 79.5 79.1 70.0 393 Racha–Svaneti 84.0 82.1 82.6 74.4 454 Age Group 15–19 76.5 71.4 72.6 63.6 861 20–24 81.5 77.2 76.4 69.1 1,099 25–29 85.3 82.7 82.0 75.0 1,191 30–34 84.4 81.4 79.8 73.6 1,168 35–39 82.8 80.0 79.3 72.7 1,051 40–44 85.6 80.5 81.3 72.6 922 Education Level Secondary incomplete or less 68.4 62.6 64.8 56.0 1,330 Secondary complete 79.4 75.0 76.5 68.1 1,568 Technicum 90.0 85.9 83.3 77.0 903 University/postgraduate 90.0 87.8 85.7 79.1 2,491 Wealth Quintile Lowest 71.7 66.0 68.3 59.6 1,093 Second 74.2 71.4 69.5 63.3 1,385 Middle 82.9 78.5 80.3 71.8 1,413 Fourth 87.0 83.8 82.9 74.1 1,037 Highest 91.3 87.8 85.9 79.9 1,364 Ethnicity Georgian 86.1 82.6 82.0 74.4 5,488 Azeri 36.9 30.6 34.7 27.3 276 Armenian 70.6 63.6 65.0 59.2 364 Other 78.4 72.4 70.1 65.0 164 Sexual Experience No 79.8 75.6 76.1 67.3 1,799 Yes 83.9 80.3 79.6 72.8 4,493 Characteristic Principal Ways to Prevent Sexual Transmission of HIV No. of Cases REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 308 Table 17.7 Percentage of Women Who Believe that Something Can Be Done to Reduce the Risk of Contracting HIV, Among All Women Aged 15-44 by Selected Characteristics Reproductive Health Survey: Georgia, 2010 High Risk ModerateRisk Low Risk No Risk at All Does Not Know Total 0.3 3.0 38.5 54.2 4.0 100.0 6,063 Residence Urban 0.3 3.8 44.4 48.1 3.3 100.0 2,942 Rural 0.2 2.1 31.4 61.5 4.8 100.0 3,121 Region Kakheti 0.2 3.2 36.3 49.1 11.2 100.0 439 Tbilisi 0.3 5.3 46.5 45.7 2.1 100.0 1,422 Shida Kartli 0.8 1.4 37.3 58.2 2.4 100.0 389 Kvemo Kartli 0.0 3.4 38.2 51.7 6.7 100.0 459 Samtskhe–Javakheti 0.3 1.0 20.7 66.6 11.4 100.0 453 Adjara 0.2 0.9 39.3 58.5 1.1 100.0 408 Guria 0.0 3.4 45.6 49.8 1.2 100.0 399 Samegrelo 0.0 0.5 44.4 53.2 1.9 100.0 472 Imereti 0.4 2.8 29.6 62.9 4.3 100.0 788 Mtskheta–Mtianeti 0.4 2.1 29.4 65.6 2.5 100.0 388 Racha–Svaneti 0.2 1.8 21.7 74.5 1.8 100.0 446 Age Group 15–19 0.2 1.6 30.3 62.3 5.6 100.0 810 20–24 0.2 3.1 38.6 53.7 4.4 100.0 1,049 25–29 0.1 3.0 39.0 55.4 2.4 100.0 1,151 30–34 0.5 4.6 40.9 49.5 4.6 100.0 1,133 35–39 0.5 3.3 42.1 49.7 4.4 100.0 1,021 40–44 0.3 2.5 41.3 53.8 2.1 100.0 899 Education Level Secondary incomplete or less 0.4 1.3 29.4 61.7 7.2 100.0 1,182 Secondary complete 0.1 1.8 31.8 61.5 4.8 100.0 1,513 Technicum 0.0 2.6 40.6 52.3 4.5 100.0 893 University/postgraduate 0.4 4.8 46.6 46.5 1.6 100.0 2,475 Wealth Quintile Lowest 0.2 2.0 28.3 63.0 6.4 100.0 1,018 Second 0.1 1.2 33.1 60.8 4.7 100.0 1,292 Middle 0.2 2.7 33.0 60.2 3.9 100.0 1,367 Fourth 0.2 3.1 43.4 50.1 3.2 100.0 1,027 Highest 0.5 5.0 48.6 43.2 2.8 100.0 1,359 Ethnicity Georgian 0.3 3.3 40.0 53.2 3.3 100.0 5,414 Azeri 0.0 0.0 22.7 69.8 7.5 100.0 169 Armenian 0.2 1.3 26.4 61.9 10.2 100.0 326 Other 0.0 1.1 32.2 54.6 12.2 100.0 154 Characteristic Perceived Risk of Contracting HIV Total No. of Cases 309 CHAPTER 18 DOMESTIC VIOLENCE Violence against women includes a wide range of be- haviors and acts that are perpetrated against women by their partners or other assailants. Domestic vio- lence—also known as intimate partner violence (IPV), “battering,” or spousal abuse—is the most common form of violence against women. It occurs in all cul- tures and affects women of all ages and all socioeco- nomic and educational backgrounds. Although vio- lence is not a primary focus of the reproductive health surveys, they provide a unique opportunity to study prevalence of violence and the characteristics of women who experience it. In addition to document- ing IPV in the context of maternal and child health, survey findings can be used to raise awareness at the individual and community levels, to help educate law enforcement and social service agencies, to influence current public health policies, to develop laws to pro- tect and benefit battered women and, ultimately, to predict future needs for support services and inter- ventions for abused women. The first two reproductive health surveys, in 1999 and 2005 (Serbanescu et al., 2001 and 2007), demonstrat- ed the presence of domestic violence in Georgia. Then a large, specialized national survey in 2009 devoted specifically to domestic violence was carried out (Ch- itashvili et al., 2010, with UNFPA support), which uti- lized WHO methodology and yielded data comparable to those from other countries. It confirmed the level of violence and provided a wealth of detail concern- ing abuse of various types. The first Georgian law on domestic violence came into effect on June 9, 2006. In this law, the definition of domestic violence goes beyond physical violence to include psychological, economic, and sexual violence: “domestic violence re- fers to violation of constitutional rights and freedoms committed by one family member in relation to an- other family member, through physical, psychological or sexual violence, coercion or threat to undertake such actions.” (Government of Georgia, Law on Pre- vention of Domestic Violence, Protection and Support of Domestic Violence Victims, June 2006). The adop- tion of the law was followed by the development and approval of two periodic Action Plans on Elimination of Domestic Violence, Protection and Support to its Victims (2006–2008 and 2009–2010). Despite new legal regulations and increased efforts to raise aware- ness on domestic violence, formal reporting of acts of domestic abuse to the authorities remained relatively unchanged —the lifetime and current IPV reported by women of reproductive age in 2009 were comparable with the 2005 levels. Since 2008, a coordination body (the State Interagency REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 310 Coordination Council on Domestic Violence) was es- tablished by presidential decree to ensure the imple- mentation of the domestic violence law. The Council, in partnership with the Young Lawyers Association of Georgia (GYLA) and with UNFPA support, developed the National Referral Mechanisms (NRM) for victims of domestic violence. In 2010 UNIFEM (United Nations Development Fund for Women) with the support of the Swedish Interna- tional Development Cooperation Agency (SIDA) and in collaboration with local NGOs and government agen- cies, implemented the project “Enhancing Prevention and Response to Domestic Violence,” which included building of two shelters for victims of domestic vio- lence in Tbilisi and Gori. Currently, numerous non- governmental organizations, such as the Anti-Vio- lence Network of Georgia, Georgian Young Lawyers’ Association, the Women’s Center, and Women for Democracy, in partnerships with donor organizations and governmental agencies, are very active in pursu- ing gender equality and violence prevention projects in Georgia. The 2010 survey included a series of questions to as- sess the burden of domestic violence. The questions, which focus principally on IPV, explore acts of violence perpetrated by current or former husbands and male partners with whom the respondent had lived as a couple. IPV, which can take a variety of forms includ- ing physical abuse, psychological abuse, and coercive sex, was documented using a modified version of the eight-item Conflict Tactic Scale (Straus, 1979). IPV in GRHS 2010 was defined as psychological, physical, and sexual abuse towards ever-married (whether le- gally or consensually) women. (a) Psychological abuse includes insults, curses, psychological threats, and gestures with intent of physical harm. (b) Physical vio- lence includes pushing, shoving, and slapping, kick- ing, hitting with the fist or an object, being beaten up, and being threatened with a knife or other weapon. Women who experienced recent physical abuse were further asked about the severity of physical injuries and whether they sought help from law enforcement agencies, family, friends, or health care providers. (c) Sexual abuse is defined as any episode when the inti- mate partner “physically forced [the woman] to have sex against her will.” In addition, all respondents were asked about their history of witnessing physical abuse between parents or experience of abuse as a child or adolescent. Recent Physical and Verbal Abuse by Having Witnessed or Experienced Parental Physical Abuse as a Child Among Ever-Married Women Aged 15–44 Figure 18.1 0% 10% 20% 30% 40% Witnessed Yes No Experienced Yes No Physical Abuse Verbal Abuse 5.2 21.6 1.3 7.2 4.3 23.3 1.4 7.1 Figure 18.2.1 20 15 10 5 0 P e r c e n t Verbal Abuse Physical Abuse Reported Lifetime Abuse by Type of Abuse Among Ever-Married Women Aged 15–44, Georgia: 1999, 2005, 2009, 2010 19 1999 8 15 7 7 7 15 2005 2009 2010 Source: GERHS 1999, 2005, 2010 and the National Research on Domestic Violence against Women in Georgia, 2009 FINAL REPORT 311 18.1 History of Witnessing or Experiencing Parental Physical Abuse The 2010 survey included questions on abuse be- tween parents when the respondent was growing up and abuse of the respondent as a child. Research into violence against women has revealed that experienc- ing and witnessing parental abuse during one’s child- hood are strong predictors of being in an abusive re- lationship as an adult (Hotaling and Sugarman, 1986). As shown in Table 18.1.1, 8% of all respondents re- ported having heard or seen abuse between their par- ents, and 8% recalled being physically abused by their parents during childhood. Compared to the 2005 survey the percentage of respondents who reported that they had experienced physical abuse as a child decreased from 14% to 8% in 2010 (not shown). The highest prevalence of witnessing parental abuse was seen in women residing in Mtskheta-Mtianeti (12%), Adjara (11%) and Kvemo Kartli (11%) regions. Expe- riences of physical abuse in childhood were mostly reported by women from Racha-Svaneti (15%) and Samtskhe-Javakheti (14%) regions. Women belong- ing to Azeri and other minority ethnic groups had the highest percentages of witnessing and experiencing parental physical abuse. There were some noticeable, but not extreme differences in the percentages re- porting these adverse childhood experiences among other socio-demographic groups. Women in rural ar- eas, with the least education, and in the lowest wealth quintile, were most likely to have such experiences (Table 18.1.1). Figure 18.2.2 25 20 15 10 5 0 P e r c e n t Lifetime Past 12 Months Reported Lifetime and Recent Abuse (Past Year) by Type of Abuse Among Ever-Married Women Aged 15–44 Verbal Abuse Physical Abuse Figure 18.2.4 Reported Lifetime Abuse by Current Marital Status Among Ever-Married Women Aged 15–44 P e r c e n t Currently Married Previously Married Verbal Abuse Physical Abuse 11 46 2 24 1 8 Sexual Abuse Figure 18.2.3 Reported Lifetime Abuse by Type of Abuse and Educational Attainment Among Ever-Married Women Aged 15–44 P e r c e n t <Secondary Complete Technicum/University Secondary Verbal Abuse Physical Abuse 21 16 12 6 5 4 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 312 Women who reported having witnessed or experi- enced paternal abuse as a child were far more likely to experience lifetime or current (during the 12 months prior to the interview) physical or psychological abuse (Table 18.1.2 and Figure 18.1). The differences are quite remarkable. 18.2 Prevalence of Intimate Partner Violence To measure the lifetime prevalence of intimate partner violence (IPV), women who ever had a marital partner (either formal or consensual) were asked if they had ever been verbally, physically or sexually abused by a partner or ex-partner. As in previous surveys, the 2010 survey shows that the prevalence of IPV reported re- mains low and relatively unchanged (Figure 18.2.1). Less than 20% of women reported lifetime psycho- logical abuse in all reproductive health surveys. Life- time exposure to physical and sexual abuse by current or previous intimate partner was reported by 7% to 8% of women. A similar percentage reported lifetime physical violence in the National Survey of Domestic Violence against Women of Georgia (Serbanescu et al., 2001 and 2007; Chitashvili et al., 2010). As shown in Table 18.2 and Figure 18.2.2, about 15% of respondents recalled been exposed to lifetime verbal abuse and 8% reported current (during last 12 months) exposure to verbal abuse. The levels of physical and sexual abuse were low, with 5% report- ing lifetime physical abuse, and 2% reporting lifetime sexual abuse. Less than 2% reported current physical or sexual abuse from an intimate partner. Despite low national prevalence of IPV, differences ex- ist according to women’s characteristics in Table 18.2. Verbal abuse and physical violence were greater, in general, among women with less formal education (Figure 18.2.3) and lowest socioeconomic status, and among women of Azeri or “other” ethnic backgrounds. The age pattern is mixed: lifetime abuse of all three types definitely rises with age, as does recent verbal abuse. However it is important to notice the higher prevalence (5%) of recent physical violence that is re- ported by young women aged 15 to 19. Surveys in oth- er countries have also indicated that younger women are often at greater risk of current violence compared to older women. Compared with currently married women, previously married women experienced far more verbal abuse, physical abuse, sexual abuse, suggesting that domes- tic abuse is a common factor associated with separa- tion and divorce (Figure 18.2.4). 18.3 Seeking Help for Intimate Partner Violence Seventy one percent of women who were subjected to physical abuse by an intimate partner sought help or disclosed their experience to others (Table 18.3.1). The majority of these women were most likely to talk about the abuse with a family member (54%) or a friend (42%), rather than to seek legal or medical help. Only 5% of women who were physically abused reported their experience to police, 3% sought medi- cal help, and 2% turned to a legal adviser (Figure 18.3.1). Overall there were relatively small differences by individual characteristics, but greater help-seeking was found among women who were urban residents, younger, and not currently married/in union (includ- ing the previously married). Legal or medical help was rarely sought, and was least likely to be sought by rural respondents, those not currently married or in union, those of low SES and in the lower wealth quintiles, also women with other than Georgian ethnicity (Table 18.3.1). The most common reasons cited by physically abused women for not seeking formal help were the embar- rassment associated with disclosing the abuse (28%) and the feeling that it was useless or would not do any good (23%). Other reasons mentioned were be- lief that the physical abuse was not very severe (10%), concerns that reporting violence would negatively af- Figure 18.3 Levels of Help-Seeking by Source of Help Among Ever-Married Women Aged 15–44, Who Reported Lifetime Physical Abuse P e r c e n t Her Family Friends Husband’s Family Police Health Provider Lawyer FINAL REPORT 313 fect the family’s reputation (10%), fear of more beat- ings or being punished (8%) and fear of divorce or ending the relationship (6%) (Table 18.3.2). The reluc- tance to reveal domestic violence outside of the fam- ily was also found in the 2009 special study of violence ((Chitashvili et al., 2010). 18.4 Aspects of Intimate Partner Relationships and Gender Norms Intimate partner violence is often triggered by a per- ceived transgression of gender norms in a family. Gen- der norms that are conducive to equity between mari- tal partners help guarantee that men and women are in an equal position to use basic social services and make social, economic, and health-related decisions. The 2010 survey sought to measure the perceived roles and responsibilities of husbands and wives in Georgia and their correlates with IPV. Ever-married respondents were asked about several aspects of their relationships with their husbands or partners, including expression of affection, tolerance of wife’s contact with her family and friends, sharing of household chores, and whether the husband insists on making all the decisions (i.e., demands the “final say”). Most respondents reported that their husbands usually shared household chores (72%). However, about half of women (50%) reported that their hus- bands frequently insist on having the final say; and 32% said their husbands need to know where they are all the time. Very few women stated that their hus- bands get angry if they speak with other men, limit their contacts with family and friends, or get very sus- picious that the wife may be unfaithful (Table 18.4.1). Behaviors of husbands that promote gender equity (e.g., sharing household chores, never insisting on having the final word in household decisions, never limiting wife’s contacts with family and friends, not be- ing suspicious or angry if she speaks with other men) were summed to create a score to classify the “gender norms status” of a family. Equal values were assigned for reports of each “positive” norm; possible scores ranged from 0 (no norm associated with gender equi- ty in the household) to 5 (all 5 positive norms existed in the family). Respondents who reported 0 or 1 posi- tive norm were classified as having relationships with low gender equity, those with 2 or 3 positive norms were classified as having average gender equity, and Agreement with Selected Justifications for Wife-beating by Experience of Physical Abuse Among Ever-Married Women Aged 15–44 Figure 18.4.2 0% 5% 10% 15% 20% Husband finds out that wife had been unfaithful Wife neglects children Wife argues with husband Wife asks husband whether he has other girlfriends Wife goes out without telling husband Wife refuses to have sex Husband unhappy with housework/cooking 25% 21 19 12 5 7 3 4 2 5 2 4 1 2 5 Ever Physical/Sexual IPV Never Physical/Sexual IPV Figure 18.4.1 Prevalence of Lifetime Physical or Sexual Abuse by Gender Equity Status of the Household Among Ever-Married Women Aged 15–44 P e r c e n t Verbal 40 35 30 25 20 15 10 5 0 Physical Sexual Verbal Physical Sexual Verbal Physical Sexual Low Gender Equity Status Average Gender Equity Status High Gender Equity Status 36 17 6 10 2 8 11 1 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 314 those with 4 or 5 positive norms were considered as having high gender equity. Most women were scored as having average gender equity (2745 of 4487 cases in Table 18.4.2. A marked pattern emerged, that women living in households with low gender equity were much more likely to be subjected to any type of violence than those who had high gender equity in their households (Figure 18.4.1). Another set of questions explored women’s accept- ance of justification for wife-beating under certain circumstances (Table 18.4.3). Overall, almost 20 per- cent of ever-married women agreed with at least one circumstance under which they consider wife-beating justifiable. The large majority of these were women who thought that the husband would be justified in hitting his wife if he found out that she had been unfaithful (19%). Agreement that wife-beating is jus- tifiable in the other circumstances included in the table was reported by 1%–5% of these ever-married women. The percent of women who were in agree- ment that wife-beating is justifiable in each of the cir- cumstances was somewhat greater among those who reported lifetime physical or sexual abuse compared to those who had never been abused (Figure 18.4.2). The difference may perhaps be confounded with oth- er factors since abuse is greater in rural areas and in low education, SES, and quintile groups. Additional details on domestic violence are found in the special 2009 study devoted to the subject (Chitashvili et al., 2010). In summary, these various findings suggest that lack of empowerment, with poor gender equity, leaves women more vulnerable to verbal, physical or sexual partner abuse. FINAL REPORT 315 Table 18.1.1 Percentage of Women Aged 15–44 Years Who Have Witnessed or Experienced Parental Physical Abuse as a Child by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Characteristic Witnessed Abuse Experienced Abuse No. of Cases* Total 8.1 8.4 6,268 Residence Urban 7.6 7.5 2,967 Rural 8.7 9.3 3,301 Residence Tbilisi 6.6 6.4 1,422 Other Urban 8.7 8.7 1,545 Rural 8.7 9.3 3,301 Region Kakheti 9.3 6.7 493 Tbilisi 6.6 6.4 1,422 Shida Kartli 4.3 10.1 392 Kvemo Kartli 10.7 9.7 546 Samtskhe-Javakheti 8.3 13.6 479 Adjara 11.1 10.2 417 Guria 6.3 6.7 395 Samegrelo 6 7 5 0 477Samegrelo 6.7 5.0 477 Imereti 8.3 9.6 804 Mtskheta-Mtianeti 12.4 10.1 391 Racha-Svaneti 7.1 14.8 452 Education Level Secondary incomplete or less 9.4 10.0 1,321 Secondary complete 9.7 8.6 1,562 Technicum 8.2 9.1 898 University/postgraduate 6.3 7.0 2,487 Wealth Quintile Lowest 9.6 10.9 1,088 Second 9.4 9.3 1,378 Middle 7.8 7.9 1,406 Fourth 9.2 9.1 1,035 Highest 5.7 6.1 1,361 Ethnicity Georgian 7.5 7.8 5,467 Azeri 12.7 13.7 276 Armenian 10.6 8.3 363 Other 15.0 17.2 162 * Excludes 24 women who reported that they did not grow up with their parents. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 316 Table 18.1.2 Percentage of Women Aged 15–44 Who Experienced Verbal, Physical, or Sexual Abuse in Lifetime or in Past 12 Months According to Whether They Witnessed Parental Violence or Experienced Physical Abuse Prior to Age 15. Reproductive Health Survey: Georgia 2010 Verbal Abuse Physical and/or Sexual Abuse Verbal Abuse Physical and/or Sexual Abuse Total 14.8 5.0 8.4 1.6 Parental Violence Yes 37.3 13.5 21.6 5.2 No 12.6 4.2 7.2 1.3 Experienced Abuse Yes 39.0 12.0 23.3 4.3 No 12.6 4.4 7.1 1.4 No. of Cases 4,487 4,487 4,487 4,487 Lifetime IPV IPV During Last 12 Months Characteristic FINAL REPORT 317 Table 18.2 Percentage of Ever Married Women Aged 15–44 Who Reported Intimate Partner Violence (IPV) in Their Lifetime and Percentage Who Reported IPV in the Last Year by Type of Abuse and by Selected Characteristicsy yp y Reproductive Health Survey: Georgia, 2010 Verbal Abuse PhysicalAbuse Sexual Abuse Verbal Abuse Physical Abuse Sexual Abuse IPV During the Last 12 Months No. of CasesCharacteristic Lifetime IPV Abuse Abuse Abuse Abuse Total 14.8 4.5 1.7 8.4 1.4 0.5 4,487 Residence Urban 13.9 4.5 2.0 7.0 1.4 0.4 2,044 Rural 15.7 4.5 1.4 10.0 1.4 0.5 2,443Rural 15.7 4.5 1.4 10.0 1.4 0.5 2,443 Residence Tbilisi 13.8 4.8 2.1 6.6 2.3 0.5 940 Other Urban 14.0 4.2 2.0 7.3 0.6 0.4 1,104 Rural 15.7 4.5 1.4 10.0 1.4 0.5 2,443 Age Group 15–19 7.9 5.0 0.0 7.3 5.0 0.0 130 20–24 9.0 2.6 1.0 5.7 1.7 0.5 639 25–29 13.1 2.7 1.3 8.9 1.1 0.6 909 30–34 15.6 4.7 2.2 8.0 1.4 0.4 1,036 35–39 18.6 6.9 2.1 9.9 1.5 0.2 944 40 44 16 9 4 9 2 2 9 0 0 8 0 8 82940–44 16.9 4.9 2.2 9.0 0.8 0.8 829 Marital Status Currently married/in union 11.4 2.4 1.0 8.4 1.0 0.4 4,098 Not currently married/in union 45.8 23.5 8.1 8.4 4.9 0.9 389 Number of Living Children 0 12 9 6 1 2 8 5 8 1 9 0 5 4720 12.9 6.1 2.8 5.8 1.9 0.5 472 1 13.6 5.2 1.9 6.4 1.6 0.3 1,285 2 15.8 3.7 1.2 10.7 1.1 0.5 2,069 3 13.5 3.2 2.0 6.7 1.2 0.6 539 4 or more 23.3 10.3 3.8 11.3 3.9 1.5 122 Education LevelEducation Level Secondary incomplete or less 20.7 6.4 2.0 12.8 2.2 0.2 801 Secondary complete 15.8 4.7 1.8 10.3 2.2 0.8 1,196 Technicum/university 12.4 3.8 1.6 6.2 0.8 0.4 2,490 Socioeconomic Status Low 23.9 8.2 2.6 14.4 2.5 0.6 462 Middle 15.0 4.7 1.7 8.2 1.3 0.5 2,011 High 12.7 3.5 1.6 7.4 1.2 0.4 2,014 Wealth Quintile Lowest 20.9 6.5 1.9 13.0 1.7 0.4 787 Second 14.9 4.2 1.6 10.0 1.4 0.6 1,032 Middl 13 0 3 9 1 3 7 1 0 8 0 3 1 017Middle 13.0 3.9 1.3 7.1 0.8 0.3 1,017 Fourth 13.5 4.8 1.8 6.9 1.8 0.5 710 Highest 13.4 3.8 2.0 6.6 1.5 0.5 941 Ethnicity Georgian 13.4 3.9 1.7 7.7 1.2 0.5 3,854 Azeri 29 6 8 9 2 3 18 1 2 5 0 4 234Azeri 29.6 8.9 2.3 18.1 2.5 0.4 234 Armenian 13.2 6.0 1.9 5.7 1.1 0.0 269 Other 26.8 10.3 2.3 15.2 4.7 0.0 130 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 318 Table 18.3.1 Percentage of Ever–Married Women Aged 15–44 Who Were Physically Abused by an Intimate Partner and Sought Help by Selected Characteristics Reproductive Health Survey: Georgia, 2010 Respondent's Family Friend Husband's Family Police Health Provider Legal Adviser Total 71.2 54.4 42.3 19.3 5.4 3.4 2.3 222 Characteristic No. ofCases Ever Sought Help Source of Help Total 71.2 54.4 42.3 19.3 5.4 3.4 2.3 222 Residence Urban 76.3 55.3 48.3 19.7 5.1 3.5 2.8 100 Rural 65.7 53.5 35.9 18.8 5.7 3.3 1.7 122 Residence Tbilisi 73.3 55.0 48.3 21.7 5.0 5.0 3.3 46 Other Urban 79.4 55.6 48.2 17.5 5.3 1.8 2.2 54 Rural 65.7 53.5 35.9 18.8 5.7 3.3 1.7 122 Age Group 15–24 82.4 54.6 52.5 22.4 0.0 0.0 0.0 18 25 34 63 7 48 4 36 8 21 8 5 0 3 2 1 4 8425–34 63.7 48.4 36.8 21.8 5.0 3.2 1.4 84 35–44 73.4 58.4 43.5 16.8 7.0 4.4 3.4 120 Marital Status Currently married/in union 64.8 48.7 37.4 19.3 5.3 5.9 3.4 129 Not currently married/in union 77.9 60.3 47.5 19.2 5.5 0.8 1.1 93 Number of Living ChildrenNumber of Living Children 0–1 79.7 63.7 43.3 24.8 6.4 2.4 3.1 94 2 65.9 46.8 44.5 15.0 5.2 5.1 1.3 86 3+ 59.1 45.0 34.9 13.0 3.0 2.4 2.0 42 Education Level Secondary complete or less 73.5 59.4 42.6 17.7 7.7 4.7 3.5 120 Technicum/university 68.7 49.0 42.1 21.0 2.9 2.0 0.9 102 Socioeconomic Status Low 71.6 58.9 40.1 29.4 10.3 3.2 1.9 45 Medium/High 71.2 53.5 42.8 17.2 4.4 3.4 2.3 177 Wealth Quintile Lowest 70 6 57 9 40 7 22 6 7 0 2 6 0 0 57Lowest 70.6 57.9 40.7 22.6 7.0 2.6 0.0 57 Second 60.7 51.7 26.6 14.9 7.1 3.7 2.6 45 Middle 74.7 58.3 37.3 23.0 0.0 2.1 0.0 47 Fourth 83.2 62.0 55.0 18.9 6.2 6.9 4.1 36 Highest 67.6 43.9 50.7 17.0 6.5 2.0 4.5 37 EthnicityEthnicity Georgian 71.4 52.8 45.0 18.6 5.7 4.5 3.0 168 Other 70.8 59.3 34.4 21.4 4.7 0.0 0.0 54 FINAL REPORT 319 Table 18.3.2 Most Commonly Cited Reasons for Not Seeking Formal Help Among Ever-Married Women Aged 15-44 Who Reported Lifetime Physical Abuse Reproductive Health Survey: Georgia 2010 Main Reason You Have Never Sought Any Medical or Legal Help No. of Cases Total Embarrassed 61 28.4 No use/would not do any good 47 23.0 Bring bad name to family 23 9.8 Injury not very severe 20 10.4 Afraid of more beatings/being punished 12 7.6 Afraid of divorce/end of relationship 9 6.3 Did not know where to seek help 7 3.1 Violence is normal/no need to complain 4 2.1 Afraid of loosing the children 2 1.2 Thought would not be taken seriously/not believed/laughed at 1 0.5 Thought she would be blamed 1 0.5 Other 7 3.5 Don't know/Refused to answer 6 3.7 No. of Cases 200 100.0 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 320 Table 18.4.1 Percentage of Ever Married Women Aged 15–44 Who Reported Specific Gender Norms in the Household By Selected Characteristics Reproductive Health Survey: Georgia, 2010 Husband Usually Shares Household Chores Husband Wants to Have the Final Say Husband Insists on Knowing Where Wife/Partner is at All Times Husband Gets Angry If Wife/Partner Speaks With Another Man Husband Tries to Limit Wife/Partner's Contact with Family and Friends Husband Often Suspicious That Wife/Partner is Unfaithful Total 71.5 49.6 31.8 6.3 4.9 4.2 4,487 Residence Urban 72.7 46.1 29.7 7.4 5.2 5.1 2,044 Rural 70.4 53.2 34.1 5.1 4.6 3.2 2,443 Residence Tbilisi 70.4 40.6 31.6 9.4 6.0 6.2 940 Other Urban 74.9 51.5 27.9 5.5 4.4 3.9 1,104 Rural 70.4 53.2 34.1 5.1 4.6 3.2 2,443 Age Group 15–24 74.4 50.1 36.6 7.6 5.3 5.2 769 25–34 72.2 48.8 32.6 6.2 4.9 3.4 1,945 35–44 69.7 50.2 29.1 5.7 4.8 4.5 1,773 Marital Status Gender Norms Characteristic No. ofCases Marital Status Currently married/in union 74.8 48.5 29.8 3.8 2.7 2.2 4,098 Not currently married/in union 41.4 59.7 50.6 29.0 24.7 22.3 389 Number of Living Children 0–1 69.3 45.6 33.3 8.8 6.3 6.0 1,757 2 72.2 51.2 31.2 4.6 4.0 2.8 2,069 3 or more 75.4 55.1 30.0 4.5 4.1 3.4 661 Education Level Secondary complete or less 68.7 54.5 36.4 7.1 6.6 4.7 1,997 Technicum/university 73.8 45.7 28.3 5.6 3.6 3.7 2,490 Socioeconomic Status Low 63.4 54.0 35.7 8.7 5.9 6.7 462 Medium/High 72.5 49.1 31.4 6.0 4.8 3.9 4,025 Wealth Quintile Lowest 69.1 56.2 38.9 6.0 5.0 3.9 787 Second 68.8 54.2 35.0 5.8 5.7 3.5 1,032 Middle 72.1 51.6 28.5 4.0 3.3 2.8 1,017 Fourth 74.6 46.5 30.6 6.9 6.2 4.7 710 Highest 72.6 42.3 28.7 8.4 4.8 5.8 941 Ethnicity Georgian 73.5 47.8 30.0 5.3 4.0 3.5 3,854 Other 59.7 60.3 43.0 12.0 10.6 8.1 633 FINAL REPORT 321 Table 18.4.3 Percentage of Ever Married Women Aged 15–44 by Whether They Had Ever Experienced Physical or Sexual Intimate Partner Violence in Their Lifetime and Their Agreement with Different Reasons That May Justify Wife-Beating Reproductive Health Survey: Georgia, 2010 Never Abused Ever Abused The husband finds out that the wife has been unfaithful 18.7 18.6 21.0 The wife neglects the children 5.2 4.8 11.5 The wife argues with her husband 3.5 3.4 6.7 Th if k h h b d h th h h th i lf i d 2 5 2 4 4 2 Agreement with a Specific Reason Total Physical or Sexual Intimate Partner Violence in Lifetime The wife asks her husband whether he has other girlfriends 2.5 2.4 4.2 The wife goes out without telling her husband 1.8 1.7 4.5 The wife refuses to have sex with her husband 1.6 1.5 4.6ppy cooking 1.3 1.2 4.4 Agreement with any reason 19.3 19.1 22.6 No. of Cases 4,487 4,265 222 Table 18.4.2 Prevalence of Lifetime Physical or Sexual Abuse by Gender Equity Status of the Household Among Ever-Married Women Aged 15-44 Reproductive Health Survey: Georgia 2010 Gender Equity Status Verbal Abuse% Physical Abuse % Sexual Abuse % No. of Cases Total 14.8 4.5 1.7 4,487 Low Gender Equity Status 35.9 16.5 5.9 907 Average Gender Equity Status 9.5 1.6 0.8 2,745 High Gender Equity Status 8.0 0.5 0.1 835 REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 322 ANNEX A: Institutional Participation National Reproductive Health Council Sandra Elisabeth Roelofs, Chairperson Georgia Ministry of Labor, Health, and Social Affairs (MoLHSA) Zurab Tchiaberashvili, Minister Andrew Urushadze, Former Minister Michael Dolidze, Deputy Minister Rusudan Rukhadze, Head of the Healthcare Department National Center for Disease Control and Public Health (NCDC) Nata Avaliani, Director General Maia Butsashvili, Deputy Director George Kandelaki, Deputy Director Paata Imnadze, Head of Science Board Neli Chakvetadze, Academic Secretary Khatuna Zakhashvili, Head of Communicable Diseases Division Lela Sturua, Head of Noncommunicable Diseases Division Marina Shakh-Nazarova, Chief Specialist Nana Mebonia, Chief Specialist Zhordania Institute of Human Reproduction Giorgi Tsagareishvili, Head, Department of In-vitro Fertilization Jenaro Kristesashvili, Head, Reproductive Function Formation Department Georgian Association of Obstetricians and Gynecologists Tengiz Asatiani, Vice President Zaza Bokhua, Secretary General Institute of Demography and Sociology Giorgi Tsuladze, Head of Department National Medical Center after Gudushauri Zaza Sinauridze, Director General John Snow Institute, Inc (JSI) Nino Berdzuli, Senior Technical Advisor for Reproductive Health Kartlos Kankadze, Country Director Curatio International Foundation Ketevan Chkhatarashvuli, President USAID/Georgia Jonathan Conley, Mission Director Jeri Dible, Director of Health and Social Development Tamara Sirbiladze, Project Officer for GERHS10 Nana Chkonia, Administrative Officer UNFPA/Georgia Zahidul Huque, UNFPA Country Director for Armenia, Georgia and Azerbaijan and the Representative in Turkey Tamar Khomasuridze, Assistant Representative Lela Bakradze, Program Analyst Marina Tsintsadze, Admin/Finance Assistant FINAL REPORT 323 UNICEF/Georgia Roeland Monasch, UNICEF Representative in Georgia Tinatin Baum, Social Policy Specialist Centers for Disease Control and Prevention, Division of Reproductive Health (CDC/DRH), Atlanta Florina Serbanescu, Survey Principal Investigator Vasili Egnatashvili, Survey Consultant Mary Goodwin, Epidemiologist Paul Stupp, Sampling Statistician (Demographer) Danielle Suchdev, Public Health Analyst (ORISE) Alicia Ruiz, System Programmer (SAIC) Fernando Carlosama, System Programmer (SAIC) Jose Luis Carlosama, System Programmer (McKing Corp.) Leo Morris, Survey Consultant (SAIC) REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 324 ANNEX B: Field and Data Entry Personnel Field Coordinators: Khatuna Zakhashvili Marina Shakhnazarova Team Supervisors: Olga Tarkhan-Mouravi (Team I) Khatuna Aladashvili (Team V) Nato Tsereteli (Team II) Rusudan Etsadashvili (Team VI) Tea Niniashvili (Team III) Sopo Datukishvili (Team VII) Dali Trapaidze (Team IV) Ia Kochiashvili (Team VIII) Team Interviewers: Team I Team V Leli Urushadze Marika Khatashvili Rusudan Chumburidze Mariam Natsvlishvili Natalia Tskipurishvili Keti Sanadze Lela Sabadze Nana Gabriadze Ana Nemsadze Tina Gabrichidze Eka Chubabria Team II Team VI Nino Shubladze Rusudan Chlikadze Tamila Lemonjava Lia Sanodze Sopo Dolbadze Maka Tevzadze Nona Papukashvili Eliso Iobashvili Eka Nodia Ketevan Napireli Team III Team VII Eka Tsertsvadze Marina Chubinidze Lia Skhirtladze Mariam Kuparadze Tea Gognadze Eka Khmaladze Tamar Dzodzuashvili Lali Kudukhova Irma Iremashvili Shorena Komladze Team Interviewers: Team IV Team VIII Marina Baidauri Marina Lashkarashvili Marina Tsereteli Anna Kasradze Nino Tsintsadze Khatuna Lomashvili Ketevan Galdavadze Khatuna Kutateladze Pikria Shavreshiani Sopo Guramishvili Data Entry Supervisors: Irina Kocharova Konstantin Kazanjian Data Entry Operators: Natela Gognadze Larisa Sedykh Gulnazi Lomsadze Susanna Shakhbudagian Liana Khuchua Irina Tkhinvaleli Tamar Pilauri Tsimi Chabukashvili-Chanadiri FINAL REPORT 325 References Alan Guttmacher Institute (1999). Sharing Responsibility: Women, Society and Abortion Worldwide. New York, NY: The Alan Guttmacher Institute. Aleshina N and Redmond G (2005). How high is infant mortality in Central and Eastern Europe and the Com- monwealth of Independent States? Population Studies; 59:39–54. Ezzati M, Lopez AD, Rodgers A, Murray CJ, editors (2004). Comparative Quantification of Health risks: Global and Regional Burden of Disease Due to Selected Major Risk Factors. 959–1108. Geneva, Switzerland, WHO. Black RE (2010). Global, Regional, and National Causes of Child Mortality in 2008: a Systematic Analysis. The Lancet 5; 375(9730):1969–87. Bongaarts J (1991). The KAP-Gap and the Unmet Need for Contraception. Population and Development Review; 17:293–313. Brown SS, Eisenberg L, editors (1995). The Best Intentions. Unintended Pregnancy and the Well-Being of Chil- dren and Families. Washington, DC (USA): National Academy Press. Cates W, Jr. (1982). Legal abortion: The public health record. Science; 215(4540):1586-1590 Centers for Disease Control and Prevention and ORC Macro (2003). Reproductive, Maternal, and Child Health in Eastern Europe and Eurasia: A Comparative Report. Atlanta, GA (USA): Department of Health and Human Services and Claverton, MD (USA): ORC Macro. Chanturidze T, Ugulava T, Durán A, Ensor T, Richardson E (2009). Georgia: Health System Review. Health Systems in Transition; 11(8):1–116. Chitashvili M, Javakhishvili N, Arutiunov L, Tsuladze L, Chachanidze S (2010). National Research on Domestic Violence Against Women in Georgia. Final Report. Tbilisi, Georgia. UNFPA. CoReform Project (2005). Review and Analysis of Reproductive Health Legislation and Policy in Georgia. Tbilisi, Georgia, USAID. DiFranza JR, Lew RA (1996). Morbidity and Mortality Associated with the Use of Tobacco Products by Other People. Pediatrics; 97:560–568. EngenderHealth (2002). Contraceptive Sterilization: Global Issues and Trends. Available at http://www.engenderhealth.org/pubs/family-planning/contraceptive-sterilization-factbook.php Finer LB and Zolna MR (2011). Unintended pregnancy in the United States: Incidence and disparities, 2006. Contraception; doi: 10.1016/j. Contraception.2011.07.013. Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM (2010). GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer. Available from: http://globocan.iarc.fr. See also Georgian European Policy and Legal Advice Centre (GEPLAC) (2008). Georgian Economic Trends Quar- terly Review. October 2008. Available at: http://www.geplac.org/eng/trends.php Georgian Ministry of Health, Labor and Social Affairs, Georgia National Reproductive Health Policy, 2006, Tbilisi, Georgia: Government of Georgia, 2007. Goskomstat, USSR (1990). Demographic Yearbook of the USSR, 1990. Moscow: Goskomstat USSR. Government of Georgia (1997). Law of Georgia of 10 December 1997 on Health Care. Tbilisi, Georgia: Govern- REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 326 ment of Georgia. Government of Georgia (2001). Law of Georgia on Medical Activities of 08 June 2001. Tbilisi, Georgia: Govern- ment of Georgia. Government of Georgia (2002). Decree #31: Measures on the Improvement of the Registration System in the Demography Statistics. Tbilisi, Georgia: Government of Georgia. Government of Georgia (2006). Law on Prevention of Domestic Violence, Protection and Support of Domestic Violence Victims, June 2006. Tbilisi, Georgia: Government of Georgia. Gwatkin, D.R., S. Rutstein, K. Johnson, R.P. Pande, and A. Wagstaff. 2000. Socio-economic differences in health, nutrition and poverty. HNP/Poverty Thematic Group of the World Bank.Washington D.C.: The World Bank. Hatcher RA, Trussel J, Stewart F, Nelson AL, Cates W, Stewart GK, Guest F, Kowal D (2004). The Essentials of Contraception: Efficacy, Safety, and Personal Considerations. In: Contraceptive Technology, 18th edition. New York, NY (USA): Ardent Media. Henshaw SK (1998). Unintended Pregnancy in the United States. Family Planning Perspectives; 30(1):24–29 and 46. Hotaling G and Sugarman DB (1986). An Analysis of Risk Makers in Husband to Wife Violence: The Current State of Knowledge Violence and Victims Vol 1, No. 2:101–124. International Planned Parenthood Federation (IPPF)(2007). Abortion Legislation in Europe. Available at http:// www.ippfen.org/ JSI Research and Training Institute, Inc (2009). Healthy Women in Georgia. Making a Difference. Tbilisi, Georgia, JSI. Kesmodel U, Wisborg K, Olsen SF, Henriksen TB, Sechler NJ (2002). Moderate Alcohol Intake in Pregnancy and the Risk of Spontaneous Abortion. Alcohol & Alcoholism; 37(1):87–92. Khomasuridze A, Kristesashvili J, and Tsuladze G (2005). Male Reproductive Health Survey, Tbilisi, Georgia: Unit- ed Nations Population Fund (UNFPA). Kristesashvili J, and Tsuladze G (2002). Adolescents’ Reproductive Health Survey, Tbilisi, Georgia: United Nations Population Fund (UNFPA). Kristesashvili J, Surmanidze L, et al. (2009). Adolescents’ Reproductive Health Survey in Georgia, Tbilisi, Georgia: EU, UNFPA, EPF. Kristesashvili, J, and Zardiashvili P (2009). “Comparative Analysis of Results of Adolescent Reproductive Health Surveys Conducted in Armenia, Azerbaijan and Georgia”, EU/UNFPA co-funded project “Reproductive Health Initiative for Youth in the South Caucasus” (RHIYC), Tbilisi. Lawn JE, Cousens S, Zupan J (2005). 4 Million Neonatal Deaths: When? Where? Why? The Lancet; 365 (9462):891–900. Mattias Öberg, Maritta S Jaakkola, Alistair Woodward, Armando Peruga, Annette Prüss-Ustün (2011).World- wide Burden of Disease from Exposure to Second-Hand Smoke: A Retrospective Analysis of Data From 192 Countries. The Lancet; 377(9760):139–46. MEASURE DHS, Demographic and Health Survey in Albania, Armenia, Azerbaijan Moldova, and Ukraine. 2005– 2010, Calverton, MD, USA Available at http://www.measuredhs.com/pubs FINAL REPORT 327 Miller WB (1994). Reproductive Decisions: How We Make Them and How They Make Us. In: Severy LJ, editor, Advances in Population, Vol 2. London: Jessica Kingsley Publishers: 1–27. Moreau C., Cleland K., Trussel J. (2007). Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception, 76(4), 267-72. Morris L, 2000. History and Current Status of Reproductive Health Surveys at CDC. American Journal of Preven- tive Medicine; 19(1 Suppl):31-4. Naimi TS, Brewer B, Mokdad A, Serdula M, Denny C, Marks J (2003). Binge Drinking among U.S. Adults. JAMA; 289:70–5. Popov AA, David HP (1999). Russian Federation and USSR Successor States: Sex and Society. In: From Abortion to Contraception: A Resource to Public Policies and Reproductive Behaviors in Central and Eastern Europe from 1917 to the Present (David HP, ed.). Westport, CT: Greenwood Press. Rahman A, Katzive L, Henshaw SL. 1998. A Global Review of Laws on Induced Abortion, 1985–1997. Interna- tional Family Planning Perspectives; 24(2):56–64. Rossier C (2003). Estimating Induced Abortion Rates: a Review. Studies in Family Planning; 34(2):87–102. Sakvarelidze L., 2010. Health and Health Care Georgia 2009: Statistical Yearbook. Georgian National Center for Disease Control and Centers for Disease Control. Tbilisi, Georgia, NCDC. Serbanescu F, Morris L, Nutsubidze N, Imnadze P, Shaknazarova M (2001). Reproductive Health Survey, Georgia, 1999–2000. Final Report. Atlanta, GA (USA): Georgian National Center for Disease Control and Centers for Dis- ease Control and Prevention. Atlanta, GA, USA. Serbanescu F and Morris L (2003). Background, in: Morris L and Sullivan JM, eds., Reproductive, Maternal and Child Health in Eastern Europe and Eurasia: A Comparative Report, Atlanta, GA, USA: CDC and ORC Macro, 1–11. Serbanescu F, Imnadze P, Bokhua Z, Nutsubidze N, Jackson DB, Morris L (2007). Reproductive Health Survey, Georgia, 2005. Final Report. Georgian National Center for Disease Control and Centers for Disease Control and Prevention. Atlanta, GA, USA. Serbanescu F, Tefft M, Shakhnazarova M, Williams D, Berdzuli N, Berg C (2009). Reproductive Age Mortality Study, Georgia, 2008 —Part II: Maternal Mortality, Atlanta, GA, USA: Georgian National Center for Disease Con- trol, JSI Research & Training Institute, Inc (JSI) and CDC. Atlanta, Georgia, USA. State Department for Statistics (2003). Population of Georgia in 2002: Statistical Abstract. Tbilisi, Georgia: State Department for Statistics. State Department for Statistics (2010). Key Population and Health Statistics. Available at: http://statistics.ge Straus MA (1979). Measuring Intra-family Conflict and Violence: The Conflict Tactics Scales. Journal of Marriage and the Family, 41:75–88. Tietze C and Henshaw S (1986). Induced Abortion, a World Review. New York: The Alan Guttmacher Institute, 1986, Chapter 8. Tsertsvadze G, Bokhua Z, Tsuladze G (2010). Doctors’ Attitudes Towards Family Planning Issues. Tbilisi, Georgia, UNFPA. Ulizzi L, Zonta LA (2002). Sex Differential Patterns in Perinatal Deaths in Italy. Human Biology; 74: 879–88. UNECE (United Nations Economic Commission for Europe (2002). Dynamics of Fertility and Partnership in Eu- REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 328 rope: Insights and Lessons from Comparative Research (Volume I). New York, USA and Geneva, Switzerland: United Nations. UNICEF (2001). Progress since the World Summit for Children: A Statistical Review. New York, NY: UNICEF. Avail- able at: http://www.unicef.org/pubsgen/ UNICEF (2005). The State of the World’s Children 2006: Excluded and Invisible. New York, NY: UNICEF. Available at: http://www.unicef.org/pubsgen/ UNICEF (2009) State of the World’s Children 2009: Maternal and Newborn Care. New York, NY: UNICEF. Avail- able at: http://www.unicef.org/pubsgen/ UNICEF (2010) Multiple Indicators Cluster Surveys-Round 4 (MICS4). Available at: http://www.childinfo.org/ mics4.html UNICEF (2011) State of the World’s Children 2011: Maternal and Newborn Care. New York, NY: UNICEF. Avail- able at: http://www.unicef.org/pubsgen/ U.S. Agency for International Development (USAID) Georgia, 2009. Tuberculosis Profile. Tbilisi, Geogia, USAID. U.S. Department of Health and Human Services (DHHS) (2006). The Health Consequences of Involuntary Expo- sure to Tobacco Smoke: A Report of the Surgeon General. Rockville, MD: DHHS and CDC. U.S. Department of Health and Human Services (2010). How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: DHHS and CDC. USSR Ministry of Health (1982). Order No. 234 of March 1982. USSR Ministry of Health (1987). Order No. 757 of June 5, 1987 and Order No. 1342 of December 1987. USSR Ministry of Health (1990). Order No. 484 of December 14, 1990. Westoff CF (1976). The Decline of Unplanned Births in the United States. Science; 191:38–41. WHO (1991). Indicators for Assessing Breast Feeding Practices (WHO/CDD/SER/91.14). Geneva, Switzerland: World Health Organization. WHO (2002). WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model (WHO/ RHR/01.30). Geneva, Switzerland: World Health Organization. WHO Framework Convention on Tobacco Control (2003). WHO Press. Geneva, Switzerland. Available at http:// whqlibdoc.who.int/publications/2003/9241591013.pdf WHO and Center for Medical Statistics and Information [CMSI], (2003). Comparison of Completeness of Data Collected by Two Systems; Evaluating Cause of Death Certification by Physician and ICD-10 Coding of Underlying Causes of Death by SDS Coding Staff. Tbilisi, Georgia: WHO and CMSI. WHO (2006). Global strategy for the prevention and control of sexually transmitted infections: 2006-2015. WHO (2008). Global Burden of Disease Report, 2004 update. Available at: http://www.who.int/healthinfo/global_burden_disease/ GBD_report_2004update_full.pdf WHO (2010). Sexually Transmitted Infections. Fact sheet N°110. WHO (2010a). Trends in Maternal Mortality: 1990 to 2008. Estimates developed by WHO, UNICEF, UNFPA and FINAL REPORT 329 the World Bank. Geneva, Switzerland: World Health Organization. WHO (2010b). Global Tuberculosis Control. Geneva, Switzerland: World Health Organization. WHO Regional Office for Europe (2011a). European Health for All Database (HFA-DB)(online version). Copenha- gen, Denmark: WHO. Available at http://www.euro.who.int/hfadb. WHO (2011b). World Health Statistics 2011. Available at: www.who.int/entity/whosis/whostat/EN_WHS2011_ Full.pdf Wilsnack SC, Klassen AD, Wilsnack RW (1984). Drinking and Reproductive Dysfunction among Women in a 1981 National Survey. Alcohol, Clinical and Experimental Research; 8(5):451–458. You D, Wardlaw T, Salama P, Jones G (2010). Levels and Trends in Under-5 Mortality, 1990–2008. The Lancet; 375: 100–03. REPRODUCTIVE HEALTH SURVEY IN GEORGIA 2010 330

View the publication

You are currently offline. Some pages or content may fail to load.