Moldova Reproductive Health Survey 1997
Publication date: 1997
• • • • REPRODUCTIVE HEALTH SURVEY MOLDOVA, 1997 FINAL REPORT Prepared by: Florina Serbanescu, MD Leo Morris, PhD Mihai Stratila, MD Octavian Bivol, MD Moldovan Ministry of Health Institute for Scientific Research of Mother and Child Care, Moldovan State Department of Statistics Family Planning Association of Moldova CHISINAU, Moldova Behavioral Epidemiology and Demographic Research Branch, Division of Reproductive Health, Centers for Disease Control and Prevention ATLANTA, GEORGIA USA United Nations Population Fund United States Agency for International Development United Nations Children's Fund December, 1998 PRINTED BY: U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention Atlanta, Georgia 30333 In memory of Einar Sandved Friend, colleague, leader CONTENTS Page PREFACE . I ACKNOWLEDGMENTS . .iii EXECUTIVE SUMMARY . v I. INTRODUCTION . 1 1.1 Background . 1 1.2 Objectives of the Survey . 2 II. METHODOLOGY. 5 2.1 Organizational Structure . 5 2.2 Questionnaire Content . 5 2.3 Survey Design . 7 III. CHARACTERISTICS OF THE SAMPLE . 11 3.1 Characteristics of the Households . 11 3.2 Characteristics of the Eligible Women . 15 3.3 Radio Listening and Television Viewing Habits.21 IV. FERTILITY AND PREGNANCY EXPERIENCE .27 4.1 Fertility Levels and Differentials.28 4.2 Induced Abortion Levels and Differentials .33 4.3 Nuptiality .38 4.4 Recent Sexual Activity .40 4.5 Planning Status of the Last Pregnancy . 44 4.6 Pregnancy Outcomes.47 4.7 Abortion Services.50 4.8 Reasons for Abortion .60 4.9 Abortion Complications .62 4.10 Future Fertility Preferences . 65 V. PREGNANCY, DELIVERY, AND MATERNAL HEALTH. 69 5.1 Prenatal Care. 71 5.2 Intrapartum Care . 80 5.3 Postnatal Care . 87 5.4 Breastfeeding . 89 5.5 Smoking and Drinking During Pregnancy . 96 5.6 Pregnancy and Postpartum Complications . 96 VI. KNOWLEDGE OF CONTRACEPTION. 103 6.1 Contraceptive Awareness and Knowledge of Use . 103 6.2 Knowledge About Contraceptive Effectiveness. 109 6.3 Knowledge About Condom's Effectiveness in Preventing STDs. 114 6.4 Knowledge About Advantages and Disadvantages of Using the Pill and IUD . 116 VII. ATTITUDES AND OPINIONS ABOUT CONTRACEPTION . 123 7.1 Opinions About the Best Method to Prevent Pregnancy. 123 7.2 Opinions on Safety of Birth Prevention Methods . 126 7.3 Opinions on the Best Source of Information About Contraception . 130 VIII. CURRENT AND PAST CONTRACEPTIVE USE 8.1 Current Contraceptive Prevalence . 133 8.2 Source of Contraception . 143 8.3 Preference for Other Methods and Dissatisfaction with Current Method . 144 8.4 Users of Non-Supplied Methods . 148 8.5 Recent Trends in Contraceptive Use. 152 8.6 Contraceptive Failure and Discontinuation. 155 8.7 Discussions About Contraception with Current Partner . 158 8.8 Reasons for Not Using Contraception . 160 8.9 Potential Demand and Unmet Need for Contraception . 161 8.10 Contraceptive Sterilization. 165 IX CONTRACEPTIVE COUNSELING. 167 9.1 Communication with Family Planning Providers . 167 9.2 Satisfaction with Counseling Services . 169 9.3 Post-abortion and Postpartum Counseling . 171 X. REPRODUCTIVE HEALTH ATTITUDES . 173 10.1 Ideal Family Size . 173 10.2 Attitudes toward Abortion. 175 10.3 Attitudes and Perceptions About Reproductive Norms and Gender Roles . 182 XL SEX EDUCATION . 187 11.1 Opinions about Sex Education in School . 189 11.2 Discussions about Sex Education Topics with Parents. 192 11.3 Sex Education Instruction in School . 196 11.4 Sex Education's Impact on Knowledge About Fertility and Contraception . . . 202 XII. SEXUAL AND CONTRACEPTIVE BEHAVIOR AMONG YOUNG ADULTS . . 209 12.1 Sexual Experience . 209 12.2 Current Sexual Activity. 215 12.3 Contraceptive Use at First Sexual Intercourse. 217 12.4 Reasons for Not Using Contraception at the Time of First Sexual Intercourse . 221 12.5 Use of Contraception at Most Recent Sexual Intercourse . 224 12.6 Opinions and Attitudes about Condoms and Condom Use. 225 XIII. HEALTH BEHAVIORS . 231 13.1 Cigarette Smoking . 231 13.2 Alcohol Use. 234 13.3 Prevalence of Routine Gynecologic Visits . 236 13.4 Breast Self-Exam. 239 13.5 Cervical Cancer Screening .241 13.6 Prevalence of Selected Health Problems .244 XIV. PHYSICAL AND SEXUAL ABUSE . 249 14.1 History of Verbal and Physical Abuse by a Partner or Ex-Partner . 249 14.2 Physical Abuse During the Past 12 Months by a Partner or Ex-Partner . 244 14.3 Forced Sexual Intercourse . 260 XV. KNOWLEDGE OF AIDS TRANSMISSION AND PREVENTION . 263 15.1 Awareness of AIDS and Other STDs . 265 15.2 Source of Information About HIV/AIDS . 269 15.3 Knowledge About HIV/AIDS Transmission. 271 15.4 Knowledge About HIV/AIDS Prevention. 275 15.5 Beliefs About Risk of HIV/AIDS Among Selected Groups and Self-Perceived Risk of HIV/AIDS . 279 REFERENCES. 283 APPENDIX A: SAMPLING ERROR ESTIMATES . 287 APPENDIX B: INSTITUTIONS AND PERSONS INVOLVED IN THE 1997 MOLDOVAN REPRODUCTIVE HEALTH SURVEY . 291 APPENDIX C: SURVEY QUESTIONNAIRE . 295 Preface In the late 1980s, Moldova entered a long period of dramatic changes as it moved from a centralized, totalitarian regime, characteristic of the former Soviet Union, to an autonomous administrative, economical, political, and socio-cultural system whose priorities are state capacity building, transition to a democratic society, and development of a market economy. During these challenging years, Moldova faced divisive ethnic disputes, economic hardships, and profound societal transformation, including rapid deterioration of the health care sector. After its independence from the Soviet Union in 1991, Moldova was no longer able to sustain an adequate health care system. Poor health services contributed to a rapid deterioration of health indicators, such as lower life expectancy, decreasing natural population growth, and increasing levels of general mortality and morbidity, including high maternal and infant mortality rates. Abortion complications were the leading cause of maternal mortality and morbidity and their costly treatment severely burdened already scarce financial resources. More information is needed to assess the reproductive health status of the population during a period of rapid changes that profoundly influence the health of women and children. In 1997. the Moldovan Ministry of Health, with technical assistance provided by the Division of Reproductive Health of the Centers for Disease Control and Prevention (DRH/CDC), conducted the first national population-based survey of reproductive health (MRHS). The survey was designed to provide the Ministry of Health, international agencies, and nongovernmental organizations (NGO's) active in the area of women's and children's health with essential information on fertility, reproductive practices of women, maternal care, maternal and child mortality, health behaviors, and attitudes toward selected reproductive health issues. The survey provides data that will assist the government in improving services related to the health of women and children. The results describe reproductive health issues in Moldova and provide a better understanding of their causes and consequences. Moreover, the survey data will improve the accountability, efficiency, and effectiveness of programs targeting the health of women, infants and children. For these programs to be successful, the needs of the targeted population must be accurately defined and appropriate interventions need to be designed, monitored and evaluated. The survey data will enhance the ability of the national reproductive health program to undertake data-based program planning, monitoring and evaluation. Mihai Stratila, M.D. MRHS National Director Institute of Scientific Research of Mother and Child Care i iv Acknowledgments We would like to acknowledge all the organizations and individuals who contributed to the various phases of the Moldova Reproductive Health Survey (MRHS). This survey was conducted by the Moldovan Ministry of Health, through its Institute for Scientific Research of Mother and Child Care (ISRMC), in collaboration with the Family Planning Association of Moldova (FPAM) and the Moldovan State Department for Statistics (MSDS). Technical assistance in survey design, sampling, questionnaire development, training, data processing, and report writing was provided by the Division of Reproductive Health (DRH) of the United States Centers for Disease Control and Prevention (CDC). Principal investigators of this study were Dr. Mihai Stratila, national director of the MRHS, and Dr. Florina Serbanescu and Dr. Leo Morris from DRH/CDC. Most of the funding for the MRHS was provided by the United Nations Population Fund (UNFPA Project MOL/97/P01), the United States Agency for International Development (USAID PASA DPE-3038-X-HC-1015-00) and the United Nations Children's Fund (UNICEF). We wish to thank the 5,412 women who made such a major contribution to our knowledge on women's health in Moldova by their participation in MRHS. Special thanks are also extended to Prof. Eugen Gladun, Minister of Health; Dr. Valentina Melnik, Dr. Eudochia Gaidau, and Dr. Petru Rosca of the Moldovan MH; Dr. Valentin Friptu, Chief of the Research Department of the ISRMC; Eugenia Mihailov, General Director of the MSDS, Anatol Craevschi, Director of the Center of Vital Statistics (CVS) of MSDS, and Vasile Pentelei, Director of Census Division (CD) of MSDS; Dr. Veaceslav Mosin, President of FPAM; and Dr. Boris Gilca, former Vice President of FPAM for their important contributions in the early planning of the survey. We are especially grateful to our Field Work Coordinator, Dr. Valeria Jolea of ISRMC, Data Entry Supervisors Ludmila Olari and Maria Usurel of MSDS/CVS, Sampling Consultant Maria Strajescu of MSDS/CV, Iacob Anghel, the survey administrator, and to our Romanian Training Consultants, Dr. Carmen Cruceanu and Doina Apostol; we also thank to Rebecca (Wyndy) Amerson of DRH/CDC for developing the survey data entry program and to Gabriela Ionascu of UNAIDS Moldova for her contribution to the HIV/AIDS chapter. Many thanks are extended to the UNFPA regional staff in Romania—Einar Sandved, UNFPA Representative and Country Director for Moldova, Rodica Furnica, Program Officer, and Cornelia Iliescu, Financial Assistant—to the UNDP Moldova staff—Ulrika Gustafson, Program Officer, Nadejda Chirica, Program Assistant, and Elena Tiurina, Chief, Administrative Section—and to the UNICEF Moldova staff—Stefan Carlos Toma, Assistant Representative and Octavian Bivol, Project Officer, Health—for their assistance in design, planning and financial management. Many thanks to Mary Ann Micka and Willa Pressman, USAID/Washington, for their continued support of the survey. Special thanks are extended to Katy Shroff, UNFPA/WHO Chief Technical Adviser, for her contribution to the early planning of the survey. We thank our dedicated interviewers and supervisors for their commitment and discipline, and the directors of the District Sanitary Directorates who facilitated the field work. iii iv Executive Summary The Moldovan Reproductive Health Survey (MRHS) was conducted from July to September 1997 and represented the fourth of seven national reproductive health surveys carried out or planned in Eastern Europe and the Former Soviet Union between 1993 and 1999 with the technical assistance of the Division of Reproductive Health of the United States Centers for Disease Control and Prevention (CDC), Atlanta, Ga. The Moldovan Ministry of Health was the principal executing agency; field work was conducted by the Institute for Scientific Research of Mother and Child Care. The State Department of Statistics provided the sampling frame and conducted data processing activities. The MRHS was designed to collect information from a representative sample of reproductive-age women throughout Moldova. The questionnaire covered a wide range of topics related to reproductive health for all women regardless of marital status and included additional questions on sex education and sexual behavior for women aged 15-24. The survey employed a three-stage probability sample design and successfully interviewed 5,412 (98%) of 5,543 women identified in sample households as eligible for interview. Two-thirds of women (68%) with completed interviews were married or in a consensual union. Almost 40% of women had more than a secondary education. The majority population is Moldovan (68%) with substantial Russian (15%) and Ukrainian (10%) ethnic groups. Romanian is the main language spoken in 60% of households, followed by Russian (27%). All interviewers were bilingual and questionnaires were in both of these languages. Nine in ten (91%) respondents stated that they watch television daily ( 93% of households have a television set) and 66% listen to the radio daily or almost every day. The total fertility rate (TFR) in Moldova is estimated at 1.8 births per woman; the rate is 1.3 for women living in the four municipalities, 1.6 for women in other urban areas, and 2.3 for rural women. The age-specific fertility rate for women aged 15-19 is 57 per 1,000, but is as high as 82/1,000 for women with an incomplete secondary education. The total induced abortion rate (TIAR) is 1.3 per woman; the 20-29 year age group contributes 60% of the total abortion rate. The TIAR ranges from 1.7 in Chisinau to 1.1 for women living in rural areas. Of women who ever been pregnant, 53% report having had an abortion; 28% report having two or more abortions. Forty-two percent of pregnancies in the five years prior to the survey were reported to be unintended (9% mistimed and 33% unwanted). The planning status of the most recent pregnancy is strongly v correlated with pregnancy outcome. Ninety percent of unwanted pregnancies and 59% of mistimed pregnancies ended in abortion. More than 90% of abortions were performed in hospital gynecological wards, including one-third of procedures performed during the first 6 weeks of gestation by vacuum aspiration (mini-abortions). About one in ten (11%) women reported early complications associated with their abortion and an additional 5% reported complications at six months following the abortion. Of all women in legal or consensual union, 62% do not want any more children. More than 80% (83%) do not want any more children if they have two children and more than 90% do not want any more children if they have three or more children. Almost all women (99%) who gave birth in the past five years had prenatal care; 73% made their first visit during the first trimester. According to the Kotelchuck Index, which assesses the adequacy of prenatal care, based on when care begins and the percentage of recommended visits made, 77% of women had adequate or more than adequate care. Women with less than adequate care were more likely to live in rural areas, to reside in the Central Region, to have not completed secondary education, and to have two or more births. About three-fourths of women received counseling during prenatal care on breastfeeding, delivery, nutrition, and the effects of alcohol and smoking. Smaller percentage (60-65%) received counseling on family planning, postnatal care and possible pregnancy complications. Virtually all deliveries in Moldova (99%) take place in maternities or ambulatory units with inpatient obstetric care ("birth houses"). Only 6% of deliveries were Caesarean. Only about one in two women had a good opinion about staff attentiveness in their place of delivery, and fewer had a good opinion about the hygiene and comfort (41-47%) and amenities such as crowding and visiting hours (30-36%). More than half (52%) were in rooms with five or more women. Three-fourths (74%) of children born to these women had post natal care; 93% of women breastfed their children but the average duration of breastfeeding was only 8.5 months with the mean duration of full breastfeeding a minimal 3.6 months. All women have heard of at least one modern contraceptive method, principally the IUD and the condom. However, only two-thirds have heard about birth-control pills or tubal ligation and only one quarter have heard of injectables or vasectomy. Knowledge levels are lower in rural areas and among young adults. Most women know or have heard about withdrawal (84%) and 69% have heard about periodic abstinence. With the exception of the IUD and condoms, women with less than a secondary education have lower levels of knowledge of all other methods. Though all women have heard about IUD's and condoms, only 72% and 66%, respectively, know how they are used. More than 75% of women do not know anything about the effectiveness of Norplant or injectables in preventing pregnancy. The same is true for one-third of the women regarding the pill and tubal Vi ligation. Most women know the IUD but only 55% think it is "highly effective" in preventing pregnancy. Three-fourths of women stated that they want more information about contraception (including 93% of young adults). Of these women, 64% said that a physician would be the most reliable source of information and 25%, mostly those of Russian background living in the Transnistria, said that the mass media would be the most reliable source of information. Contraceptive prevalence among women in union in Moldova is 74%, with 50% using modern methods, principally the IUD ( 38%). The second most common method is withdrawal (22%). There are minimal differences in prevalence by geographic area although use of modern methods is significantly higher in urban areas (56%) and in Transnistria (62%), where 48% of married women use the IUD. Modern method prevalence is highest among Russian (63%) and Gagauzan (56%) women and lowest among Moldovan women (47%). One out of four users among Moldovan women use withdrawal. Only 23% of married women with no children are using contraception, which may reflect the pressure to have a child soon after marriage. Although more than 90% of women with three or more children do not want any more children, only 5% have had a surgical contraception. Seventy-two percent of modern method users obtain or obtained their method in public sector clinics or maternities and 24% in pharmacies. Because pharmacies are in a process of privatization, it is difficult to differentiate among public, private, and mixed ownership pharmacies. Four out of five women (80%) currently using contraception were satisfied with their current method. Overall, 20% preferred another method but this proportion varied significantly by method used; only 7% of IUD users preferred another method compared with 21-25% of pill and calendar users and 41% of condom and withdrawal users. Most dissatisfied users (excluding IUD users) wanted to switch to IUD use. The most common reasons they have not switched to the IUD include "still thinking about it", fear of side effects, cost, and "the doctor did not recommend it." One-third of dissatisfied withdrawal and calendar users stated that they have had an accidental pregnancy while using the method. Most of dissatisfied condom users mentioned that their partner complains about using a condom or they are "unpleasant to use." Every respondent who was currently using a traditional method was asked whether a number of factors were "important or somewhat important" in their decision not to use a more effective method. Most women stated that fear of side effects, lack of knowledge about modern methods, partner preference, and cost or availability of modern methods were the major factors that influenced their decision to not use a modern method. It is notable that 68% of traditional method users vi i perceived that their method was more effective or equally effective as modern methods such as the IUD and the pill. This perception was not borne out by the results of the survey. The one-year failure rates for calendar and withdrawal users were 23% and 24%, respectively, compared with 13% for condom users, 6% for pill users and 2% for IUD users. Except for the IUD (6%), discontinuation rates were high at one year; 42-44% for traditional methods, 50% for the condom and 56% for pill users. The potential demand for contraception is estimated at 60% of all women and 79% of women in union (39% for previously married and 13% for never-married women). However, as 17% of all women and 23% of women in union are using traditional methods, unmet demand ( women using less effective methods or non-users) is estimated at 23% of all women and 29% of women in union. These percentages represent 230,000 and 200,000 women, respectively, who are at risk of an unintended pregnancy. Most women who were using clinic-based methods were doing so upon the advice of their physician; tubal ligation (98%), IUD (80%) and the pill (69%). Sixty percent of condom users were doing so on the advice of their partner. Only one-half of women received counseling about other methods or about their method's effectiveness. Three-fourths (76%) did receive counseling about possible side effects. Of women using modern methods in the past five years, 22% said they were very satisfied and 66% said they were satisfied with their family planning provider. For women who have had an abortion in the last five years, only 60% received counseling about contraception following their most recent abortion and only 40% were given a method or obtained a prescription for a contraceptive method. In addition to exploring attitudes about family size and induced abortion, the MRHS also included questions related to attitudes that surround reproductive decision making. Reproductive- age women in Moldova say that 2.2 is the ideal mean number of children for a young family today. This figure ranged from 1.9 in the Transnistria region to 2.5 in the Central region. Overall, the proportion of respondents saying that a woman should always have the right to decide about her pregnancy, including resorting to abortion, was 81%. Only 1% of women opposed pregnancy termination under any circumstance and 18% agree with the acceptability of abortion for certain reasons. The majority of women (74%) believe that all people should marry and women should be virgins when they marry (66%). However, only 7% of women agree that child care is only a woman's job. Most women (74%) say that women are interested in discussing contraception with their partners and 58% say that men are interested in discussing contraception with their partners. Almost all women (98%) think that age appropriate sex education should be taught in school; 62% say that school-based courses on reproductive biology ("how pregnancies occur") should start by age 13, including 42% who favor these classes by age 12; 58% say that courses on STDs and viii contraception should start by age 13, including 38% who supported these courses by age 12. Although 78% of young adults have discussed the menstrual cycle with parents, less than 30% have discussed HIV/AIDS, other STDs, or methods of contraception. Young adults were more likely to have discussed these topics with their parents if they had school-based sex education, but even for this group, only 37% have had discussions with their parents. Of young adults who have had sex education topics in school, almost 90% had topics related to reproductive biology and the menstrual cycle but only half had a talk related to HIV/AIDS or other STDs, and only one-third discussed anything about contraceptive methods. Results indicate that the quality of teaching should be improved, as only 39% of young adults knew the time during the menstrual cycle when conception is most likely to occur and 30% did not think it was possible to get pregnant following the first sexual intercourse. The majority of young adults did not know or had misinformation about the effectiveness of most contraceptive methods. About half of 15-24 year-old women report that they have had sexual intercourse: 21% of 15-19 year-olds and 83% of 20-24 year-olds. Among these young adults, 52% ( 26% of the total) said that their first intercourse was premarital: two-thirds of 15-19 year-olds and slightly less than one-half of 20-24 year-olds. Premarital sexual experience was related to residence; 37% of young adults in the four municipalities reported premarital sexual experience, compared with 25% in other urban areas and 19% in rural areas. Only one-third of young adults with premarital sexual intercourse used contraception at first intercourse, primarily condoms (13%) and withdrawal (16%). Russian and Ukrainian young adults were more likely to use contraception at first premarital intercourse than were Moldovans. The principal reasons for non-use at first premarital relation were that sexual intercourse was not expected or "she did not think about using a method." Only 18% of young adults who first had sexual intercourse after marriage used contraception; 60% of non-users said that "they wanted to get pregnant," again showing the pressure to have a child soon after marriage in a traditional society. Contraceptive use improves dramatically after unmarried women suffer a pregnancy or enter into a more stable relationship; 66% (40% modern methods, primarily condom) of women in this category said they or their partner used contraception during their most recent sexual intercourse. Health behaviors were also investigated in the survey. Smoking prevalence is still low among reproductive-age women in Moldova; only 6% reported they were currently smoking. However, prevalence is higher among urban women (12%), previously married women (13%), and Russian women (13%). Almost one-half (46%) of women drink alcoholic drinks; 16% were classified as "frequent drinkers." Of women who have had sexual intercourse, 70% had a routine gynecologic exam in the past year; 11% had never had an exam or had not had one in more than three years. Overall, two-thirds of women have heard of breast self examination (BSE) but only 38% ix of women aged 35-44 do a BSE every month. Only 43% of sexually experienced women said they had a cervical cancer screening in the past year. Almost one-in-four (23%) women had never heard of cervical cancer screening. One-fifth (21%) of women have been diagnosed with pelvic inflammatory disease (PID) or anemia (19%). Both urinary tract infection and high blood pressure have been diagnosed in 14% of reproductive-age women. In recent years, physical and sexual abuse have come to be recognized as significant public health problems. Thus, a module was added to the survey instrument to measure abuse by a current or former partner, recognizing that the survey estimates are likely to underestimate the true population prevalence. One-fifth of women (21%) reported verbal or physical abuse; 14% suffered some sort of physical abuse during their lifetime. A higher prevalence was reported by rural women, previously married women, lesser educated women and women whose partners had a lower educational level. Fourteen percent of women reported abuse in the 12 months preceding the survey; 6% reported physical abuse by their partner. Of these women, one-third reported injuries and 7% required medical treatment. Four percent of women stated that they have been forced to have sexual intercourse against their will. Almost all women have heard of AIDS and the principal sexually transmitted diseases (syphilis and gonorrhea). However, of the 99% of women who have heard of AIDS, only 79% knew that an HIV/AIDS infection could be asymptomatic. The most important sources of AIDS information were TV/radio (56%) and magazines and pamphlets (20%). Only 7% of women got their information from a health professional. Although most women knew about the proven means of HIV transmission, they also had much disinformation; more than 50% thought HIV could be transmitted by kissing, being bitten by a mosquito, going to a barber, nail parlor or dentist, and donating blood. Only 60% mentioned condoms, 49% mentioned using clean needles, and 48% said that one should be monogamous as preventive methods to cut the risk of HIV transmission. Most women correctly identified individuals with risky behaviors as having high risk of HIV infection (e.g. prostitutes, intravenous drug users, and homosexuals). Surprisingly, two-thirds of women attributed high risk of infection to unmarried sexually experienced men and women contrasting to only 10% who believed that married individuals have a high HIV risk. However, only less than one percent of women believed that their personal risk of getting infected is high whereas 67% believed they do not have any risk, including one-half of sexually experienced unmarried women who said that unmarried sexually experienced women had a high risk of contracting HIV infection. X CHAPTER I INTRODUCTION 1.1 Background The Republic of Moldova is a former republic of the Soviet Union located in Eastern Europe between Romania and Ukraine (see map). Moldova covers an area of 13,000 square miles and has a population of nearly 4.5 million inhabitants (1995 Census projections). Slightly less than half the population (47 percent) lives in urban areas, and approximately 700,000 reside in the capital city of Chisinau. The country is administratively divided Into 40 districts, called raions, and four municipalities (Chisinau, Tiraspol, Balti, and Bender) of at least 100,000 people. Tiraspol, Balti, and Bender, which have populations ranging from 130,000 to 180,000, are characterized by their industrial enterprises. Apart from the four municipalities, the other urban settlements are distributed throughout the country and are principally small towns, with populations varying from 2,000 to 20,000 inhabitants (49 towns out of a total of 64). The majority of these towns are administrative and industrial centers for processing agricultural production. More diversified functions are found in towns such as Ribnitsa, Soroca, Orhei, Ungheni, and Cahul, each with a population of approximately 45,000. The total number of rural settlements is 1,607. National programs are developed and coordinated at the national level and are administered, along with other local government activities, at the raion level. Moldova is divided into four major geographic regions: Center, North, South, and Transnistria'. Economic, social, ethnic and cultural differences still persist among the regions due to Moldova's unique history and geographical location. At the national level, the health system is directed by the Ministry of Health, which sets the budget for health care, coordinates services and is responsible for health policy. Local health care is administered by the local authorities and the Ministry of Health through the raional health offices. They monitor all local health services, report communicable diseases, supervise immunization and other preventive activities, and regulate environmental hazards. Health services are provided 1 See Table 1.1 at the end of the chapter for the listing of raions in each region 1 through three types of health care facilities: a) primary health care network, represented by health posts and ambulatories in rural areas and polyclinics in urban areas; b) secondary health care network, consisting of rural, central district, and municipal hospitals; and c) tertiary health care, delivered by specialized municipal and republican level hospitals, polyclinics, and research institutes. As part of health care reform, the current government plans to generalize family planning services throughout the country. A certain emphasis was placed on developing the Family Planning and Health Reproduction Unit within the Ministry of Health whose tasks include: developing a family planning promotion plan, providing guidance and quality control in family planning and abortion services, organizing an evaluation system, preparing FP curricula for medical and nursing students, ordering and stocking contraceptives, and preparing a logistics plan for distribution. The continuous decline in the number of abortions performed from 1991 to 1996 (from 68.2 to 42.6 per 1,000 women aged 15-49) and the increase in contraceptive availability are considered to be results of the recently developed FP policy. However, the lack of a communication and reporting system within the newly developed FP network, combined with the lack of previous nationwide studies on reproductive health, hamper the collection of valuable information needed to evaluate the current situation and to make informed program and policy decisions. The Moldovan Ministry of Health decided that the best and most timely way to collect needed representative data would be a nationwide household survey of women of childbearing age regarding reproductive health and family planning issues. The Moldovan Reproductive Health Survey (MRHS) was conducted from July to September 1997, with 5,412 women of childbearing age interviewed in their homes. The response rate was 98%. Since this was the first ever national household-based reproductive health survey conducted in the country, the high response rate not only adds confidence in the data but also demonstrates that this methodology is feasible for gathering population-based health information in Moldova. 1.2 Objectives of the Survey The improvement of reproductive health in Moldova is a difficult and complex task, given the recent political, economical, and social changes in the area. The survey was specifically designed to meet the following objectives: -to assess the current situation in Moldova concerning fertility, abortion, contraception and 2 various other reproductive health issues; -to enable policy makers, program managers, and researchers to evaluate and improve existing programs and to develop new strategies; -to measure changes in fertility and contraceptive prevalence rates and study factors that affect these changes, such as geographic and socio-demographic factors, breast-feeding patterns, use of induced abortion, and availability of family planning; -to provide data necessary to develop sex education and health promotion programs; -to obtain data on knowledge, attitudes, and behavior of young adults 15-24 years of age; -to provide information on the level of knowledge about AIDS transmission and prevention; -to identify and focus further reproductive health studies toward high risk groups. The survey provides data that will assist the Moldovan Government in improving services related to the health of women and children and was proposed in conjunction with the UNFPA- sponsored reproductive health (RH) activities in Moldova, which consist of several components intended to increase the use of effective contraception, reduce the reliance on induced abortion as a means of fertility control, and, more generally, to improve RH. Specific projects supported by UNFPA in Moldova include ongoing support to the Government for developing a national RH plan, provisions of contraceptives, and training of family planning providers. In addition, the national RH plan is receiving support from USAID (family planning logistics management, information/ education/communication activities), IPPF (provision of contraceptives), and UNICEF. 3 4 CHAPTER II METHODOLOGY 2.1 Organizational Structure This survey could not have been carried out without the cooperation of several organizations. Funding for the MRHS was provided principally by the United Nations Population Fund (UNFPA). Additional funding was provided by the United States Agency for International Development (USAID) and the United Nations Children's Fund (UNICEF). The Moldovan Ministry of Health (MOH) was the principal executing agency, responsible for overall survey implementation. Fieldwork was conducted by the Institute for Scientific Research of Mother and Child Care (ISRMCC) of the MOH, which coordinated the recruitment and training of interviewers and all aspects of data collection. The Institute was assisted by interviewers and staff of the Family Planning Association of Moldova (FPAM). The Moldovan State Department for Statistics—Census Division (MSDS/CD) provided the sampling frames based on the 1989 census (urban sample) and the 1997 rural enumeration registries (rural sample). The MSDS Center for Vital Statistics (MSDS/CVS) also provided personnel to carry out data entry and edit operations. The Division of Reproductive Health (DRH) of the United States Centers for Disease Control and Prevention (CDC) provided assistance in survey design, questionnaire development, and in all technical areas of the survey. Interviews were administered at the homes of respondents by 20 intensively trained female interviewers, most from the ISRMCC and the FPAM. There were five survey teams, each consisting of a fieldwork supervisor and four interviewers. Interviewer training, carried out immediately before the survey field work began, was organized and conducted by staff from the ISRMCC and DRH/CDC and lasted six days. In parallel with the first two weeks of field work, a DRH/CDC computer specialist installed data entry/edit software and, with the help of an UNFPA Romanian consultant, trained the Moldovan staff in its use. 2.2 Questionnaire Content The questionnaire was first drafted by CDC/DRH consultants based on a core questionnaire used in the 1993 Romanian Reproductive Health Survey. This core questionnaire was reviewed and modified by Moldovan experts in reproductive health and family planning, as well as by USAID and 5 UNFPA. Based on these reviews, a pretest questionnaire was developed and field-tested in April 1997. The questionnaire, developed in Romanian, was translated into Russian after the pretest. All interviewers spoke these two languages. The MRHS questionnaire covered a wide range of topics related to reproductive health in Moldova. Specific areas included: - Social, Economic and Demographic Characteristics - Pregnancy History - Use of Women's Health Services - Morbidity During Pregnancy - Family Planning Awareness and Use - Knowledge and Opinions about Specific Contraceptive Methods - Reproductive Health Attitudes - Contraceptive Counseling - Sex Education, Sexual Behaviors, and Contraception among Young Adults - Women's Health Issues - Knowledge about HIV/AIDS Transmission and Prevention - Violence Against Women The questionnaire had two components: (1) A short household questionnaire used to collect residential and geographic information, select information about all women of childbearing age living in sampled households, and information on interview status. This module was also used to randomly select one respondent when there was more than one eligible woman in the household; (2) The longer individual questionnaire collected information on the topics mentioned above. The major reproductive health topics on which information was collected were: pregnancies and childbearing (a complete history of all pregnancies, including planning status of pregnancies in the last five years, a detailed history of abortions within the last five years, including postabortion counseling, and the history of all births within the last five years, including the patterns of utilization of health services during pregnancy, maternal morbidity, infant health and breast-feeding); family planning (knowledge and history of use of methods of preventing pregnancy, current use of contraception, source of contraception, reasons for not using, reasons for use of less effective methods of contraception, future fertility preferences and intentions to use voluntary sterilization); women's health (health behavior and use of women's health services, tobacco and alcohol use); reproductive health knowledge and attitudes (especially regarding birth control pills, condoms, and IUDs); knowledge about HIV/AIDS transmission and prevention; domestic violence, including violence during the most recent pregnancy; history of sexual abuse; and socioeconomic characteristics of women and their husbands/families. The young women (15-24 years of age) were 6 asked additional questions on sex education, age and contraceptive use at first sexual intercourse, and sexual behaviors. Most issues have been examined by geographic, demographic, and socio-economic characteristics, making it possible to identify the segments of the population with specific health needs or problems. 2.3 Survey Design The 1997 MRHS was designed to collect information from a representative sample of women of reproductive age throughout Moldova. The universe from which the respondents were selected included all females between the ages of 15 and 44, regardless of marital status, who were living in Moldova when the survey was carried out. The survey employed a three-stage sampling design using two sampling frames (one for urban areas and one for rural areas) provided by the MSDS. The urban sampling frame was based on the 1989 census, whereas the rural sampling frame consisted of a list of the 1,607 villages in the country, recently updated for household composition in January-April 1997 for an agricultural registry. In the first stage, 128 census sectors in urban areas and 122 villages were selected as Primary Sampling Units (PSUs) with probability proportional to the number of households in each census sector/village. In the second stage of sampling, clusters of households were randomly selected in each census sector/village chosen in the first stage. Before second-stage selection in urban areas, the Census Division of the MSDS redefined each 1989 census sector selected as a PSU for street boundaries, converted the maps and listings from Russian to Moldavian, and updated the sector's household composition in collaboration with personnel from the local health care units. A cluster of households was randomly selected from the updated sector lists of the PSUs in urban areas and from the household listings in the villages selected as PSUs in the first stage. (Since there were roughly equal numbers of urban and rural households, the sample was designed to be geographically self-weighting.) In each sample strata, urban and rural, the third stage consisted of the random selection of one woman if there were two or more eligible women (aged 15-44 years) living in the same household. Since only one woman was selected from each household containing women of reproductive age, all results have been weighted to compensate for the fact that some households included more than one eligible woman. Except for Table 2.1, all tables in this report present weighted results. The unweighted number of cases, used for variance estimation, are also shown in each table. 7 Cluster size determination was based on the number of households required to obtain an average of 20 interviews per cluster. The total number of households in each cluster took into account estimates of unoccupied households, average number of women 15-44 per household, the interview of only one woman per household, and an estimated response rate of 90% in urban areas and 92% in rural areas. In urban areas, the cluster size with a yield of 20 interviews, on average, was determined to be 45 households. In rural areas, because the average number of women 15-44 per household varies considerably by raion, the average number of households needed to obtain 20 complete interviews varied from 42 to 60. 8 As mentioned above, interviews were conducted at the respondent's homes by trained female interviewers. These interviews generally lasted 45 to 60 minutes. Almost all women selected to participate in the survey agreed to be interviewed and were very cooperative. Of the 11,506 households selected, 5,543 were found to include at least one 15-44 year-old woman. Of these women, 5,412 were successfully interviewed, for a response rate of 97.6% (Table 2.1). Less than one percent of selected women refused to be interviewed, while another 1.3% could not be located. Response rates were slightly better in rural areas (98%) than in municipalities and other urban areas (97%). In Chisinau (not shown), the response rate was 96%; nearly 3% of women selected in the sample could not be located. As shown in Table 2.2, the geographic distribution of the sample, by residence and region, is very close to official figures of the population distribution for 1996, estimated by the Moldovan State Department for Statistics. 9 The percent distribution of women in the sample by five-year age groups is compared with the 1994 official estimates (the most recent estimates by age group) in Table 2.3. Compared with these estimates, the survey sample has slightly over-represented adolescent women (15-19 year- olds) and under-represented women aged 40-44 by about two percentage points. However, several factors may have contributed to the differences observed: first, there is a three-year difference between the time the official estimates were calculated and the survey was implemented; second, the official estimates are projections of the age composition recorded by the 1989 census and thus dependent on assumptions used in projecting the aging of a cohort; finally, official estimates include any possible age misreporting that occured in the census. 10 CHAPTER III CHARACTERISTICS OF THE SAMPLE 3.1 Characteristics of the Households As shown in Table 3.1.1, most of the households with eligible women (62% of total households) have three or four persons; households with six or more persons are relatively rare (11%). Households of single women and households with only two persons (presumably childless couples) are also not common (10%); these types of households are more frequent in urban areas (3% and 11%, respectively) than in rural areas (1% and 5%, respectively). One- or two-person households are considerably more common in Chisinau than in any other region. Conversely, households with six or more persons are the least prevalent in Chisinau and other urban areas (5%), and the most prevalent in the South (19%) region. 11 On average, a typical household is composed of four persons. Households in urban areas contain fewer persons (3.6 per household) compared to rural households (4.3 per household). Again, the mean number of persons per household is higher in the South and Central regions (4.4 and 4.3 persons). The larger household size in rural areas can be partially explained by higher fertility levels (see Chapter 4). The mean household size is lowest in Chisinau, where a higher proportion of women live in single households and fertility is the lowest in the country (TFR=T.3 children per woman). Table 3.1.2 and Figure 3.1 show the percentage of respondents living in households with basic amenities by residence. On average, only one in two women has central heating at home, only 43% have flush toilets, and only about one-third (37%) live in households with a telephone. The proportion of households with such amenities varies significantly by residence and region. 12 Urban residents are five times more likely than rural residents to have central heating, 15 times more likely to have flush toilets, and three times more likely to have a telephone. Chisinau has by far the highest prevalence of households with basic amenities; almost all households have central heating (90%) and flush toilets (88%), and telephone coverage is the highest in the country (56%). The Central region, mostly rural, is the least developed. Central heating is available for only a third of households, and flush toilets and telephones are present in about a sixth and a fourth of households, respectively. Among durable consumer goods, television is available in almost every household (93%), with slightly higher coverage in urban areas (95%, vs. 91% in rural areas) and in Transnistria (97%). Similarly, almost all households have refrigerators (90%), especially in urban areas (96%) but less frequently in the Central region (82%). As expected, virtually all households in rural areas have vegetable gardens, orchids, or vineyards (97%), whereas only one in two households in urban areas have such gardens. 13 The proportion of women who live in households with automobiles is fairly low. Only about one in four women said that she or her family owned a car. Families living in Chisinau and other urban areas and those residing in Transnistria were slightly more likely to own a car. Video recorders are still not very widespread in Moldova. Only 23% of women in urban areas and 10% in rural areas said they own a video recorder. Also, very few families own a vacation home (villa) or a secondary residence (12%). The proportion of women who have a secondary residence was almost four times higher in urban areas, compared with rural areas (18% vs. 5%). The level of household crowding is another important household characteristic. Crowding was determined by dividing the total number of persons living in the household by the total number of rooms in the house (not including kitchen and bathroom); women were classified as living in crowded conditions (more than one person per room) or not living in crowded conditions (one or fewer persons per room). Overall, more than a half (59%) of reproductive-age women live in crowded conditions. Crowding is significantly more prevalent in urban households than in rural households (73% vs. 45%), though the average number of persons per household is lower in urban areas than in rural areas. The most crowded households are in Chisinau (79%) and Transnistria (65%); the least crowded are in the South region (46%). 14 All these household basic amenities and goods were taken into account in assessing the socio-economic status of the household. Equal values were assigned for possession of each amenity or good, including living in uncrowded conditions. For each respondent, these values were combined into a score whose percent distribution is shown in Figure 3.1.2. The score was further divided into terciles to create three levels for the socio-economic status variable. Respondents with a score of 0-3 amenities were classified as living in households with low socio-economic status; those with scores between 4 and 6 were classified as having middle socio-economic status; and those with scores of 7 or higher were considered as having high socio-economic status. 3.2 Characteristics of the Eligible Women General characteristics of women with completed interviews, by residence, are shown in Table 3.2.1. Overall, 36% of the sample are young adults from 15 to 24 years of age. The age distribution is slightly younger in rural areas; here, youg adults represent 38% of the women, compared with 34% in urban areas. Only 24% of women did not complete secondary education (less than 10 years of school). About 38% completed secondary education, either in academic schools (gymnasiums and high schools) or in vocational schools (professional high schools). Almost 40% of women attended higher education: nearly in four have completed a short-term technical college and one in six have attended or completed university education. Women in urban areas were more likely to be better educated than women in rural areas. The urban-rural difference is most pronounced at the postsecondary level, where a significantly higher proportion of women (50% in the four municipalities and 44% in other urban areas) completed technical college or university training, compared with 29% of their rural counterparts. Two-thirds of women with completed interviews were currently married (66%) or lived in a stable consensual union (2%). Women residing in rural areas were more likely to be in legal or consensual marriage (72%) compared with women living in the four municipalities or other urban areas (69% and 64%, respectively). Consistent with the pattern of a rapid decline in birth rates, which characterizes all countries of the region, Moldova is also a low-fertility country, with the total fertility rate barely at the replacement level (2.1 children per woman in 1994). Overall, 30% of women in the sample were childless, one in four have only one child, almost a third have two children and only 13% have three or more children. As expected, fertility has been higher in rural areas. This is reflected in the 20% of rural women who have had three or more children, compared with 10% in urban areas and 5% in the municipalities. Most Moldovan women (62%) live in households classified as middle socio-economic status; women living in municipalities or other urban areas were much more likely to be classified as living in upper socio-economic households than rural women (25% and 28%, respectively, vs. 6%). The highest proportion of respondents with lower socioeconomic status (35%) were living in rural areas. 15 16 17 Most respondents are orthodox (94%), with no significant differences between the urban and rural areas. Three percent of women declared that they have no religion. The proportion of women with no church affiliation was higher in urban areas (5%) than in rural areas (1%). Most women (63%) are employed outside the household. In rural areas, 35% were not working, compared with almost 40% in urban areas. The ethnic diversity of Moldova is illustrated in Table 3.2.2. About two-thirds of respondents reported themselves to be Moldovan, 15% Russian, 10% Ukrainian, 3% Gagauzan, 3% Bulgarian, and 1% of other ethnic backgrounds. Romanian and Russian are the two principal languages spoken in the household. Variation in ethnic background and main language spoken in the household by residence and region are shown in the table. As shown in Table 3.2.3, most Moldovan and Russian respondents reported that they speak their own language in the household. The main language spoken in the household of Ukrainian respondents is more likely to be Russian. Respondents of Gagauzan or Bulgarian background are equally likely to speak either Russian or their native language in the household. Marital status is shown for each residential area by age group in Table 3.2.4. By age 24, two-thirds of women are married or in a stable consensual union and additional 6% have been previously married. By age 34, the proportion of women currently or ever married rises to 98%. Women in rural areas are slightly more likely to marry younger. For example, 13% of rural women 18 aged 15-19 and 81% of rural women aged 20-24 have had marital experience compared with only 10% and 59%, respectively, in municipalities. Marriage dissolution among older women is twice as high in municipalities as in rural areas. Only 8% of rural women aged 35-39 and 11% of rural women over 40 reported that they were previously married, compared with 15% and 20%, respectively, in municipalities. 19 As expected, women in urban areas are better educated in each age group; among women aged 20-24 residing in municipalities or other urban areas, 83% and 79%, respectively, have at least completed secondary school, compared with only 65% in rural areas. Also, the proportion of women with university education is four and two times, respectively, higher in municipalities (35%) and other urban areas (18%) than in rural areas (8%). The urban-rural disparity in education is less pronounced among older residents (Table 3.2.5). 20 3.3 Radio Listening and Television Viewing Habits Information about mass media habits in a population could have important programmatic implications for future interventions designed to improve reproductive health knowledge, attitudes and utilization of services. For this reason the 1997 survey included questions about radio listening, television viewing, exposure to family planning messages, and opinions about the acceptability of placing family planning messages on radio and television. As shown in Table 3.3.1, virtually all women (91%) reported that they watch some television daily and 55%—73% of respondents said they listen to the radio daily or almost every day. Thus, broadcasting health messages on television or distributing them through radio stations could reach the majority of women of childbearing age and may contribute immensely to increasing their awareness about reproductive health issues. Rural residence, younger age, and less-than-complete secondary education were somewhat associated with lower levels of daily listening to radio or watching television. Women living in households classified as having lower socio-economic status had significantly lower viewership of television (72%), as 27% of these women reported that they did not have a TV (compared with less than 2% of women with middle and high socio-economic status); Ukrainians and other ethnic groups depended less on the radio. All respondents were asked what television channels they most often watch. As shown in Table 3.3.2, the majority of women regularly watch several Russian language channels (ORT, ACT, XXI, NTV, St. Petersburg TV) and the national channel, TV Moldova, which broadcasts in Romanian (64%). Russian channels are generally more popular in urban areas (91%), including Chisinau (90%), Transnistria (94%), and among women with living in households with high socio- economic status. Moldovan ethnic women are less likely to watch these channels (75%) compared with other ethnic groups. TV Moldova is watched more often by women in rural areas (75%) and residents of the Central region (83%). Women of Moldovan ethnicity are twice as likely as other ethnic groups to watch this channel. About a third of women (35%) regularly watch Romanian national channels, including the private channel ProTV. Again, viewership of these channels is higher among rural women, residents of the Central region, and Moldovan women. Since Romanian is spoken by 77% of women in rural areas and 90% of residents in the Central region, a preference for TV Moldova and Romanian channels among these subgroups is no surprise. Other channels broadcasted in Moldova are regularly watched by far fewer women. The regional channel TPR, which broadcasts in Transnistria in Russian language, is regularly watched by 16% of all women, but is preferred by 74% of women residing in Transnistria (by comparison, less than 10% of women in other regions watch this channel) and by 42% of Russian women. 21 Other regional channels (e.g. TV Balti, TV Cahul, TV Comrat) were fairly popular only in their broadcasting areas. TV Ukraine (11% overall) has a 23% viewership among women of Ukrainian background. TV Catalan (6% overall) is relatively popular in Chisinau (20%); the private channel TV6/MTV is mostly watched by urban women (5%), women living in Chisinau or Transnistria (6%), and Russian women (6%). Not surprisingly, Western European channels (e.g. CNN, BBC, RAI, EuroNews), which require cable television, are watched by only a minority of women, mostly urban residents and those living in affluent households. 22 23 24 25 and Radio Romania (16%). Characteristics of listeners follow the same patterns as those for television preferences. Whereas Radio Moldova and Radio Romania are most popular among women living in the mostly rural Central region (73% and 25%, respectively) and women of Moldovan ethnic background (65% and 21%, respectively), Radio Russia has far more listeners in Transnistria (63%) than in other regions and more listeners among women of Russian and Ukrainian backgrounds. Radio Polidisk is popular in Chisinau (33%); as are Radio Nova (19%), Radio Plus (16%), and Unda Libera (15%). Radio Ukraine attracts listeners in the Transnistria region (16%) and women of Ukrainian background (17%). Radio Polidisk is most popular among young adults (17%). Within the past six months, few women (27%) reported exposure to family planning information on the radio (Table 3.3.4). Exposure to family planning information on TV was somewhat higher: 42% of respondents reported seeing family planning messages on television during that time. Women in urban areas, women aged 25-34, currently married women, and better educated women were slightly more likely to report exposure to family planning messages through either radio or TV. Women in Transnistria reported slightly higher exposure to radio messages (29%), whereas those living in the Central region had slightly more exposure to TV messages (45%). Respondents who regularly listen to Radio Ukraine (35%), Radio Romania (34%), Radio Russia (32%), and Radio Plus (32%) were slightly more likely than other women to say they have heard messages about contraception on the radio. Women who regularly watch TV Ukraine (56%), TV Balti and other local channels (53%), TV Catalan (52%), and Romanian channels (49%) were more likely than other viewers to have seen TV information about family planning within the last six months. The relatively low exposure to mass media information on family planning contrasts with women's desire to have these messages on radio or TV. Almost all respondents (93%) said that information about contraception should be broadcast on radio and television (data not shown). 26 CHAPTER IV FERTILITY AND PREGNANCY EXPERIENCE During the last several years of social and economic crisis, Moldova policy makers and the public health community have been concerned about the demographic changes in their country. Parallel with the increase of general mortality and morbidity rates, Moldova experienced unusually high rates of infant mortality (22/1,000 live births in 1995), maternal mortality (41/100,000 live births), neonatal morbidity (313/1,000 live births) and maternal morbidity (40.8/100,000). The rate of childbearing has fallen to the replacement level of slightly more than two births per woman. Consequently, population growth has declined nearly to zero. The average life expectancy is reported to be 66 years. Induced abortion rates, in spite of a recent decline, continue to be very high (43 abortions per 1,000 women aged 15-49 in 1996). The policy makers of Moldova are eager to learn more about these demographic changes so they can define appropriate policies under the current health care reform process. One of the objectives of the MRHS was to assess the current levels and trends of reproductive behaviors, and to identify factors that might change behaviors. The findings presented in this chapter are particularly useful in assisting policy makers and program managers to design programs that respond to the reproductive behavior of the population and to tailor programs to meet the needs of key subgroups. In order to obtain information on reproductive patterns, the questionnaire included a series of questions about marriage, divorce, sexual activity, contraceptive use (see Chapter V), childbearing and use of induced abortion, infertility, desired family size, planning status of all pregnancies in the last five years, and information about prenatal care for all births during the last five years. Information about pregnancies (births, abortions, and fetal losses) was collected through a complete pregnancy history for each woman up to the time of interview. The survey data represent an important addition to vital statistics routinely compiled at the local and state level, because the survey included many background characteristics not included on birth certificates and abortion registries. In addition, the survey explores in depth the circumstances surrounding each abortion or birth within the last five years, documenting utilization of prenatal care and abortion services and the prevalence of pregnancy-related morbidity. 27 4.1 Fertility Levels and Differentials Current levels of fertility and abortion were estimated using age-specific fertility and abortion rates. The total fertility rate (TFR) and the total induced abortion rate (TIAR) were computed by accumulating the age-specific fertility or abortion rates and multiplying the sum by five. The TFR and TIAR can be defined as the average number of events of each type (births or induced abortions) a woman would experience during her reproductive lifetime (15-44) if she would be the subject of the currently observed age-specific rates. Numerators for the age-specific event rates were calculated by selecting pregnancy outcomes that occurred during the 36-month period preceding the survey and grouping them (in five-year age groups) by the age of the mothers at the time of pregnancy outcome (calculated from the mothers' reported date of birth). The denominators for the rates represent the number of woman-years lived in each specified five-year age group by those mothers during the three-year period preceding the survey. 28 Consistent with the recent fertility decline, the total fertility rate for the three years preceding the survey ( July 1994-June 1997) was 1.8 births per woman (see Table 4.1.1). In order to compare the survey data with the most recent vital statistics estimate (TFR=2.1 births in 1992-1994), we also computed the total fertility rate for the period July 1991-June 1994. The resulted fertility rate was also 2.1 births per woman (not shown). Similar to other countries in eastern Europe, fertility in Moldova displays an early peak in the age pattern, with the highest level among 20-24 year-old women and the next highest among 25- 29 year-olds (Table 4.1.1 and Figure 4.1). Notably, fertility among the youngest women is quite high (57 births per 1,000 women aged 15-19). As a result, almost 60% of the TFR is contributed by women aged 15-24, 83% by women less than 30 years of age. Women aged 35-39 and 40-44 have minimal contributions to the total fertility; their age-specific fertility rates account for only 5% and 2%, respectively, of the overall fertility. Table 4.1.1 also presents age-specific marital fertility rates. Fertility in Moldova is concentrated within marital union. Marital fertility rates for all age groups were higher than age- specific fertility rates for all women, and the total fertility among married women was twice as high as for all women, suggesting by implication that extramarital fertility plays a minor role in overall fertility. These findings are consistent with the cumulative past fertility of women interviewed in the MRHS which was calculated as the percent distribution of women by number of live births, stratified by current age of each woman at the time of the interview (Table 4.1.2 ). Overall, 31 % of all women aged 15-44 had not yet had a live birth at the time of the interview, but only 9% of women currently in union had not had their first child. Although relatively few women reported births before age 20, by age 29 almost all women had given birth. Only 6%-8% of women at least 30 years of age were childless. Table 4.1.2 also shows an obvious two-child family size pattern with only a minority of women having three or more children (13% of all women and 18% of currently married women). Table 4.1.3 shows the age-specific fertility rates and total fertility rates among different subgroups. Urban-rural residence is an important determinant of fertility. Women living in municipalities had, on average, one child less than rural women in the three-year period preceding the interview. Fertility in other urban areas (1.6 births per woman) is slightly higher than in municipalities (1.3 births per woman) but lower than in rural areas (2.3 births per woman). All age- specific fertility rates were higher among rural residents; the differences are particularly important among the younger women (15-19 and 20-24 years of age), whose age-specific fertility rates were twice as high in rural areas compared with municipalities. Women living in the central region of the country (which is essentially rural since the only urban settlement, Chisinau, is mentioned separately) have the highest level of fertility (2.4 birth per woman). Residents of Chisinau and 29 30 women living in Transnistria—where two other municipalities, Tiraspol and Bender, are located—had the lowest fertility rates (1.3 and 1.6 births per woman). Most differences in age- specific fertility rates by region are among young adults, especially among those living in Chisinau, where the rate of women 15-19 was the lowest in the country (21 per 1,000 women aged 15-19). The age-specific fertility rate for this age group in other regions was at least three times higher than in Chisinau. There is an inverse relationship between fertility and education, with less educated women consistently reporting the highest fertility rates. Nevertheless, fertility differences according to education level diminish among older women. Socio-economic status (SES) is also inversely related to fertility level. Women with low SES had, on average, 2.4 births per woman, compared to 1.7 and 1.4 births per woman among women with middle and high SES. The age-specific fertility rate among low SES young adults was the highest in the country. 31 32 Moldovan women had higher fertility levels than women of Russian ethnic background, whose low total fertility rate (1.3 births per woman) is comparable with fertility levels of women in Russia, according with the most recent survey estimates (Goldberg H. et al., 1998). Russian ethnic young women had much lower age-specific fertility rates than any other ethnic group. Ukrainian women had the highest fertility rate among women aged 15-19 (82 births per 1,000 women aged 15-19), but their fertility declined rapidly at older ages. 4.2 Induced Abortion Levels and Differentials For many decades, the levels of induced abortion in the former Soviet Union have been among the highest in the world. Due to widespread acceptability and liberal legal regulations, induced abortion was often a substitute for contraception. Before the dissolution of the USSR, Moldova had the sixth-highest abortion rates among the 15 Soviet republics, at about 75 abortions per 1,000 women aged 15-49 (Popov, 1996). Since then, official statistics have indicated that abortion rates have gradually declined (from 65.6/1,000 in 1992 to 53.5/1,000 in 1995, 42.6/1.000 in 1996, and 34.4/1,000 in 1997) but the abortion-to-live-birth ratio remained fairly stable, at about one abortion for each live birth. 33 To better estimate the impact of induced abortion on fertility in Moldova, we studied differentials in induced abortion rates for the same three-year periods and for the same characteristics used in the analysis of fertility. Age-specific abortion rates in Table 4.2.1 and Figure 4.1 represent the proportion of women in a specific age group who terminated their pregnancies by induced abortion or mini-abortion within the three-year period preceding the survey. They were calculated using the age of the woman at the time of pregnancy termination. The average of the age-grouped abortion rates gives the general abortion rate (per 1,000 women aged 15-44) of 43.3 during the past three years, almost identical to the rate reported by official statistics (43.2/1,000). Similar to the fertility pattern, the age pattern of abortions in Moldova is concentrated at younger ages. The highest age-specific abortion rate occurred among women aged 25-29 (81/1,000), followed by rates of 74 per 1,000 among 20-24 year-olds. These age groups contribute 60% of the total induced abortion rate. Although the abortion rate decreases as age increases, abortion rates are higher than fertility rates for women over age 30. These findings suggest that Moldovan women complete their desired family size at younger ages, after which most pregnancies are unintended and intentionally terminated. The benefit of permanent methods of contraception for these women is obvious, but less than three percent of all women were using these methods, indicating that an information campaign would be needed to explain the advantages of permanent methods. A comparison of age-specific marital induced abortion rates reveals that induced abortion rates for married women were higher than those for all women and, by implication, higher than those for unmarried women. Since most women (89%) are married by age 25, marital abortion rates differ little from abortion rates for all women aged 25 and above. As shown in Table 4.2.2, there was a slight difference in abortion rates between municipalities (1.5 abortions per woman) and other urban (1.3) and rural residents (1.1), but this was less than the urban-rural fertility difference. Women residing in Chisinau had the highest abortion rate, which was twice as high as women residing in the South region of the country (1.7 vs. 0.9 abortions per woman). The TIAR was inversely correlated with education level but the association was less stronger than for fertility. However, the age-specific abortion rate for 15-19 year-olds with less than complete secondary education was twice as high as the abortion rates for 15-19 year-olds with higher educational attainment. Induced abortion rates were slightly higher among women living in households with high SES (1.5 abortions per woman) than among women with low or middle SES. Recourse to abortion tended to be higher among Ukrainian women, especially among the youngest age groups (26/ abortions per 1,000 women aged 15-19 and 101 abortions per 1,000 women aged 20-24). Table 4.2.3 shows that slightly more than one-third (39%) of all women of reproductive age reported having had at least one induced abortion. Urban women, women in Transnistria, and 34 35 36 Russian and Ukrainian women were more likely to report having had at least one abortion. The likelihood of having an abortion is positively associated with age, education and socioeconomic status. It is not surprising that the proportion having had at least one abortion increases with age, as exposure to pregnancy increases. Although very few teenagers reported any abortions (2%), by ages 20-24 the percentage rises to 16% and almost one-half of 25-29 year-olds reported having at least one abortion. For women aged 35 or more, almost two-thirds said they had at least one abortion. Since not all women were sexually experienced and not all of them were exposed to the risk of an unplanned pregnancy and a subsequent abortion, we refined the denominator to include only women who have ever had a pregnancy. Table 4.2.3 and Figure 4.2 also present the percentage distribution of the number of abortions for women who have ever been pregnant. Almost half (47%) of ever-pregnant women reported they never had an abortion; one in four (25%) said they had only one abortion, 15% two abortions, and 13% three or more abortions. Women who reported multiple abortions were more likely to live in urban areas or in Transnistria, to be older, better educated, with a high socioeconomic status, and of Russian or Ukraininan ethnic background. 37 4.3 Nuptiality Marital status is an important variable since the main exposure to the risk of pregnancy occurs among women who are married or in a consensual union. Although the MRHS does not include an exhaustive history of the living arrangements for women 15-44 years of age, data collected illustrate the current and past marital (both formal and consensual) status and age at first formal or consensual union (Figure 4.3). At the time the survey was carried out, about two-thirds of women aged 15-44 were currently married (66%) or living with a partner (2%). Eight percent were widowed, divorced, or separated (formerly married or in a consensual union). Almost one in four women (23%) had never been married or lived with a partner (see Table 4.3). Women living in rural areas were slightly more likely to be currently married than urban women (70% vs. 63%) and were less likely to be currently cohabitating. The proportion who were previously married was higher in urban areas than in rural areas (10% vs. 6%). Thus, urban women appear to be less likely than rural women to get married and less likely to stay married. Women residing in Chisinau were less likely to be currently in a marital relationship, although they were the most likely to have consensual unions. The proportion of all women who were in a formal or consensual union starts at about 11 % among 15-19 year olds, increases rapidly to 66% among women aged 20-24 and 87% among 25-29 year olds, reaches a maximum of 89% for women aged 30-34, and then slightly declines for older women, as a result of marital dissolution. Consensual unions were slightly more prevalent among women 20-24 years of age. Separation, divorce and widowhood increase with age, reaching a peak of almost one in seven women aged 40-44. The proportion of never-married women decreases abruptly: it is 88% among teenagers, 28% among women 20-24 years of age, 6% among women aged 25-29, and 2% among women aged 30-34. The proportion of women married or in union is higher among women with technical college (78%). After controlling for current age, a quite different pattern was observed (data not shown). Among women aged 20-24, the likelihood of being in a marital relationship, either consensual or formal, was inversely correlated with education, suggesting that women tend to delay marriage until after completing their education. Consensual unions do not vary significantly with education level. Women employed at the time of the survey were more likely to have ever been in union compared with those who were not working, presumably because unemployed women were younger and have had less time to establish marital relationships or wanted to delay these relationships to complete their education. 38 39 4.4 Recent Sexual Activity Information about current sexual activity is crucial in estimating the proportion of women at risk of having an unintended pregnancy and therefore in need of contraceptive services. It also has major implications in the selection of a contraceptive method that best suits the reproductive behavior and fertility preferences of each individual. Detailed information on the proportion of women in need of family planning services and their contraceptive choices are shown in Chapter VIII. Overall, 81 % of the women aged 15-44 interviewed in MRHS reported they had previously had sexual intercourse (Figure 4.4.1). However, not all women who had intercourse were currently 40 sexually active (within the month preceding the interview). Of all women, only 62% reported sexual intercourse within the last month and 7% reported intercourse one to three months prior to the interview. If we exclude women who have never had intercourse, 76% of sexually experienced women were currently sexually active (data not shown). In Table 4.4 and Figure 4.4.2, information on sexual activity status arc presented by marital status and by current age. Among women who were married or living with a partner, 85% reported having intercourse at least once within the last month and 6% had intercourse two or three months ago. They constitute the majority (94%) of those classified as currently sexually active (data not shown). Only 35% of previously married women were in a current sexual relationship; most (61 %) had their last sexual intercourse more than three months ago. Conversely, while only 20% of never- married women had ever had sexual intercourse, more than two-thirds of those sexually experienced had their last sexual encounter within the last three months. 41 42 Almost 4% of all women (slightly more among women currently in union) were either pregnant or in postpartum abstinence at the time of the interview and were not included in the analysis of current sexual activity. Among women married or living with a partner, there was little difference in the proportion of women currently sexually active by background characteristics (data not shown). The only notable exception is for younger women and for nulliparous women who were less likely to report current sexual activity mostly because a larger proportion of them were pregnant or in postpartum abstinence. Figure 4.4.2 also shows that younger women were less likely to report past or current sexual activity. However, 50% of young adults have had sexual intercourse, with 38% reporting sex within the previous three months (83% of sexually experienced young women). Sexual behavior among young adults is discussed in more detail in Chapter XII. 43 4.5 Planning Status of the Last Pregnancy For each pregnancy ended in the past five years, women were asked a series of questions to determine whether the pregnancy was intended (wanted at the time it occurred), mistimed (wanted at a later time) or unwanted. Mistimed and unwanted pregnancies together are classified as unintended pregnancies (Westoff CF, 1976). Each respondent with a pregnancy ended since January 1990 was asked to recall accurately if "just before" she got pregnant she "wanted to get pregnant then," she "wanted to get pregnant later," or she "did not want to get pregnant then or any time in the future." This report includes only estimates of planning status for the last pregnancy. One common problem in collecting data on intendedness status of pregnancy in fertility surveys is the incomplete reporting of induced abortions; abortion under-reporting necessarily implies that unintended pregnancies will be under-reported to the extent that abortions are under-reported. 44 45 Another problem that might occur for pregnancies ending in live births is the postpartum rationalization. Women are asked to report retrospectively their thoughts about the wantedness status of pregnancy at conception. Some of them will change their feelings after the child is born and may be reluctant to admit that it was an unintended pregnancy at conception. Therefore, the planning status of the last pregnancy almost certainly represents an underestimate of mistimed and, particularly, unwanted conceptions. Table 4.5 and Figure 4.5 present the percent distribution of women according to the reported wanted status of the last pregnancy in the last five years, by selected characteristics. Despite the under- reporting of unintended conceptions, the figures in Table 4.5 show some important differences in the level of pregnancy intendedness among various subgroups. These data may underscore the need to address the risk of unintended pregnancy differently for various subgroups. They also may influence policies and contraceptive services which should be tailored for different planning status groups. For example, those with mistimed pregnancies may need effective reversible methods of contraception, whereas those with unwanted pregnancies should be offered long-term or surgical contraception. Only 57% of women of childbearing age, regardless of their marital status, said their most recent pregnancy was intended at the time of conception, whereas 9% report it as mistimed (wanted at a later time) and 33% unwanted. Thus, almost one in two women reported the last pregnancy as unintended, but most of them (77%) reported it as unwanted rather than mistimed. The planning status of the most recent pregnancy is strongly correlated with pregnancy outcome (see also Figure 4.5). Almost 90% of women whose last pregnancy resulted in a live birth said the conception was planned; 9% said it was mistimed, and 4% said it was unwanted. As expected, almost all women whose last pregnancy ended in induced abortion declared the pregnancy to be unintended (96%). It should be noted that a relatively high proportion (21 %) of women whose last pregnancy ended in miscarriage or stillbirth reported it as an unwanted conception; this is almost six times the proportion of women with live births who reported an unwanted pregnancy. Although some of this difference may underscore the negative influence of unintendedness on pregnancy outcome, it is also plausible that some of these outcomes may have been induced abortions reported as spontaneous abortions or stillbirths. Planning status of the last pregnancy varied substantially by residence. Women in urban areas were more likely to experience unwanted pregnancies than those in rural areas (38% vs. 28%). The percentage of unintended pregnancies was much lower among younger women (29%) and increased progressively with age (45% among 25-34 year-olds and 59% among 35-44 year-olds). 46 Among younger women, spacing failures were more common, with a ratio of mistimed to unwanted pregnancy of almost 1 to 1). Among women aged 25-34 and 35-44, unwanted pregnancies outnumbered mistimed conceptions by 4 to 1 and more than 10 to 1, respectively. The same pattern can be seen when the planning status of the last pregnancy is examined by the number of living children. Women who had never had a live birth and women with one child were less likely to report an unintended last pregnancy (30% and 37%, respectively) than were women with two or more live births. Among childless women, 11 % of last pregnancies were mistimed and 18% were unwanted, whereas for women with three or more children far more pregnancies were unwanted (61%) than mistimed (15%) since these women were more likely to have reached the desired family size. Although young women and childless women reported slightly more mistimed pregnancies, the relatively high proportion of unwanted pregnancies among these subgroups may reflect, as other researchers point out (Kauffman RB et al., 1996), poor understanding of the survey question, conflicting or ambivalent feelings about the last pregnancy, or indecision regarding childbearing. The level of unintended pregnancy is directly correlated with education, probably reflecting a greater propensity to use family planning among better educated women. The more education the women had, the more likely they were to have had an unwanted pregnancy in the past five years. The proportion of women who declared their last pregnancy to be unwanted increases from 27% among those who did not complete a high school education to 37% for college graduates. The survey showed there were almost no differences in the levels of mistimed or unwanted pregnancies between women of different ethnic background. 4.6 Pregnancy Outcomes Table 4.6 presents the percent distribution of the outcome of all pregnancies that ended during the five years prior to the survey. About one in two pregnancies (53%) resulted in a live birth, 37% in induced abortion and 9% in spontaneous abortions. Induced abortion was commonly used by all women but its prevalence varied substantially by their background characteristics. Urban women had a significantly higher likelihood to end a pregnancy through abortion than rural women (45% vs. 29%) and their likelihood to carry the pregnancy through term was significantly lower (44% vs. 61%). By region, women residing in Chisinau and predominantly urban Transnistria had higher rates of induced abortion compared with the rest of the country (48% and 44%, respectively). 47 Recourse to induced abortion was two times lower among adolescents (17%) than among 20-24 year-olds or 25-34 year-olds (30% and 46%, respectively) and almost four times lower than among older women (62%). The induced abortion to live birth ratio was directly correlated with age, increasing from 0.2 abortions for one live birth among adolescents to 2.2 abortions for one live birth among women aged 35 or more. The likelihood that a pregnancy would end in abortion varied directly with education (from 33% among less educated women to 41% among women with the highest education level) and with socio-economic status (from 27% among low-SES women to 50% among high-SES women). Russian and Ukrainian women were more likely than Moldovans and other ethnic groups to rely on abortion (44%-45% vs. 35% and 30%, respectively). The use of abortion was also heavily influenced by pregnancy order (all prior pregnancies, including live births, induced abortions, miscarriages, or other outcomes). Women with no prior pregnancies were the least likely to have pregnancies ending in abortion (8%) and the most likely to have a live birth (80%). The likelihood of abortion increases rapidly if a woman had any prior pregnancies (see also Figure 4.6); from women with one prior pregnancy, whose likelihood of abortion is lower than that of having a live birth, to women with two prior pregnancies who had an almost equal likelihood to resort to abortion or to keep the pregnancy, to women with three or more prior pregnancies who were substantially more likely to end their pregnancies in abortion than in a live birth. Thus, the induced abortion to live birth ratio was directly correlated with pregnancy order, increasing from 0.1/1 among women with no prior pregnancies, to about 1/1 among women with two prior pregnancies, to almost 2.5/1 among women with four or more prior pregnancies. The likelihood of an induced abortion is also heavily influenced by the planning status of the pregnancy at the time of conception. The examination of pregnancy outcomes according to their planning status allows us to see to what extent unplanned pregnancies are aborted, as opposed to resulting in unintended births. Almost all pregnancies reported as planned ended in a live birth (84%) and almost all unwanted pregnancies ended in an abortion (90%). Only about one of 20 pregnancies (5%) to women who want no more children resulted in a live birth. Most mistimed pregnancies (59%) were aborted and only one in three (32%) resulted in a live birth. 48 49 4.7 Abortion Services As is the case with all former Soviet republics, Moldova was subject to the liberal abortion legislation and regulations issued by the former U.S.S.R. Abortion on request was available within the first 12 weeks of gestation since the Soviet decree issued in November 1955. With several additions and modifications, this law has remained in force essentially unchanged. Additional regulations were issued to introduce vacuum aspiration for early abortion (Order 757, June 1987, Russian Ministry of Health), to permit induced abortion during the first 28 weeks of gestation on medical, genetic, judicial, and social grounds (Order No. 1342 of December 1987, Russian MH), and to allow "commercial abortions" performed by private practitioners (Order No. 250 of March 1988, Russian MH). 50 The previous Soviet abortion legislation was modified by the Moldovan government in August 1994 (Order no. 152, Moldovan Ministry of Health) with new provisions issued when Moldova subscribed to the WHO live birth and stillbirth definitions. Abortion on request continued to be provided up to 12 weeks of gestation, but the limit for late abortions (for medical, genetic. judicial, and social reasons) was lowered to 21 weeks. Abortion up to 28 weeks is allowed only in cases of congenital syphilis or severe fetal malformations (Order No. 103. of March 1995). Under the current law, induced abortion, performed by either vacuum aspiration or sharp curettage, is permitted only in government facilities as an inpatient procedure free of charge (but with admission and discharge on the same day, if no complications occur). Abortion on request is performed up to 12 weeks of gestation after compulsory screening for tuberculosis, syphilis. gonorrhea, and other genital infections; HIV/AIDS tests are performed only for high-risk women. All genital infections should be treated before the abortion procedure. Generally, pregnancy termination is carried out 5-10 days after the first visit in which the woman requested an abortion; however, delays may occur if the woman has to be treated for genital infections. The lengthy waiting time between the first visit and hospital admission could presumably push a 10-to-12-week pregnant woman to seek pregnancy termination outside the health system. In addition, the risk of her reason for hospitalization becoming public knowledge at work (doctors are required to mention the procedure on the certificates of temporary incapacity to work and to notify the territorial health care unit about the abortion) could further contribute to seeking an illegal abortion outside the system. Currently, illegal abortions are responsible for about one-eighth of maternal deaths. However, the cause is unknown for more than 50% of maternal deaths (UNICEF, 1997). Unofficial sources report that most of these deaths with cause unknown are abortion-related. The 1997 MRHS collected information on the last four abortions performed since January 1992 in a detailed abortion history, which included questions about the reason for abortion, type of abortion, place where the procedure was performed, abortion payments, number of nights, if any, spent in the hospital, and the presence or absence of early and late abortion complications. Data were collected starting with the most recent procedure in an attempt to minimize recall biases. Of 1,352 abortions reported to have occurred since January 1992, 99% were recorded in the abortion history. The other 1% were experienced by women with more than four abortion procedures in this interval and were not recorded. Not one abortion performed outside the health system was reported. Since illegal abortions (either self-induced, performed by lay persons, or performed by doctors outside the health system) must be reported to the police, it is very likely that women were reluctant to admit 51 these outcomes, in spite of the interviewer's assurance of anonymity. Almost all pregnancies (85%) were reported to be terminated in the first trimester of gestation. However, women's reports on this issue are subject to several possible biases, including irregular menses, problems in recalling the event and reluctance to admit abortions beyond the legal gestational limit. Half of all abortions (53%) were reported to be performed between 7 and 9 weeks of gestation, 33% under 7 weeks, 2% at 10-12 weeks, and 15% as late abortions (13 weeks or more). Numbers are too small to draw any statistical conclusions, but late abortions are inversely correlated to woman's education, socioeconomic status, and parity (27% of women with no prior pregnancy reported late abortions, compared to only 12% of women with one or more prior pregnancies); late abortions are more common among women from rural areas and residents of the Central and South regions. Late abortions have decreased from 17% in 1992-1993 to 11% in 1996-1997, while early abortions (under 7 weeks) have increased from 29% to 39%. Until recently, the classical method of termination of pregnancy in the first trimester was dilatation and curettage (D&C). By Order No. 757 of the Ministry of Health Care of the USSR, issued in June 1987, early pregnancy termination by vacuum aspiration was legalized. The same order legitimized vacuum aspiration as an outpatient procedure, but it may have been used as such by doctors outside the government health system several years before the legislation (Popov, 1996). This procedure, also known as menstrual regulation or menstrual extraction, involves aspirating the uterine cavity and induction of uterine bleeding in women whose menstrual period is no more than 20 days overdue (roughly corresponding to maximum 6 weeks of pregnancy). In the USSR menstrual regulation was called "mini-abortion" because the primary intent was to perform an early termination of pregnancy on women who wished to do so following a positive pregnancy test. By contrast, menstrual regulation does not require a pregnancy confirmation and is not regarded legally as an abortion; it is often performed in countries with restrictive abortion legislation on women concerned that they might be pregnant but who have not had a pregnancy test. Table 4.7.1 shows that of all abortions reported by survey respondents since 1992, from 22% to 43% were reported to be mini-abortions, depending upon characteristics of the women. Mini- abortions were more prevalent among urban respondents than among rural residents (38% vs. 26%) and among women living in Chisinau or the Northern region. The proportion of abortions classified as mini-abortions was inversely correlated with woman's age and increased directly with the level of education and socioeconomic status. As shown in Figure 4.7.1, the proportion of mini-abortions more than tripled between 1988 (first year after legalization) to 1996. 52 53 By law, all abortions should be performed in maternities or gynecologic wards and abortion patients are released in the same day of the intervention if they do not have postabortion complications. Until recently (before Order No. 152 was issued in August 1994). polyclinics and women's consultation centers were permitted to perform mini-abortions. Currently, only three large ambulatory units in Chisinau (in close vicinity to Ob/Gyn hospitals or wards) are allowed to carry out such procedures. As shown in Table 4.7.2, the vast majority of induced abortions reported since 1992 were performed in gynecological wards (93%). About 5% were performed in maternities, which usually perform induced abortions only for medical conditions, and 2% were carried out in ambulatory units (mostly abortions performed before 1994). There is little variation in induced abortion prevalence by place of performance. Abortions in maternities are more prevalent in urban areas (7%) than in rural areas (3%), probably because of referrals of complicated cases to big hospitals in urban areas. Outpatient abortions were slightly more prevalent in Chisinau, among youngest women (15-24 years of age), increased slightly with education and socioeconomic levels, and were mostly early abortions (less than 7 weeks). 54 55 56 Although abortion is an inpatient procedure, patients are released the same day and do not have to spend the night in the hospital. Survey results show that the majority of women (84%) who have had abortions since 1992 were released the same day (Table 4.7.3). Overall, 9% of abortions required hospitalization for one night, 4% for two or three nights, and 3% for four nights or more (Figure 4.7.2). The length of hospital stay varied with women's characteristics, gestational age, type of abortion procedure, and presence or absence of abortion complications. Hospital stay was significantly longer in Transnistria, compared with all other regions. In Transnistria only 73% of patients were released on the same day, compared with 81% to 90% in other regions. About one in five women (19%) in Transnistria were released the next day, but 5% were hospitalized for four or more days. For all women, abortion hospitalization was directly correlated with age and inversely correlated with socio-economic status. Relatively small proportions of mini-abortions (8%) were hospitalized, and most stays lasted only one night. Women having conventional abortions ( D&C) were almost three times more likely to require hospitalization (20% vs 8%); 8% of these hospital stays were two days or longer. 57 Hospitalization for abortion was inversely correlated with the number of prior gestations (data not shown). Women with no previous pregnancies (first gestation) most often spent at least one night in the hospital (24%) compared with women with one (15%), two (12%), or three previous gestations (12%). The proportion of hospitalized abortions increased again among women with four or more previous pregnancies (20%). Hospitalization was directly correlated with gestational age, increasing from 9% for early abortions (under 7 weeks of gestation), to 19% for abortions performed at 7-12 weeks of gestation, and 21% for second trimester abortions, probably because the type of abortion procedure and the risk of complications are strongly affected by gestational age. Almost one-half of abortions with early complications required at least a one-night stay and one-fifth required hospitalization for four or more nights. At the time of the survey, abortion procedures were officially free of charge in Moldova—a new regulation passed in 1998 stipulates payments of 46 Moldovan lei (about $10) for mini- abortions and 64 Moldovan lei (about $15) for conventional abortions. However, most women (67%) who reported abortions between January 1992 and the time of the interview said they had to make unofficial payments (in money or gifts) to medical personnel. Table 4.7.4 presents the distribution of these payments by selected characteristics. Overall, the average amount paid for an abortion was 41 lei, and ranged from no payment to 460 lei; 17% of women paid less than 40 lei, 20% paid 40-99 lei, and 13% paid 100 lei or more, which represents the average monthly salary for a governmental employee. For one in six women (16%), the payments were only gifts of unknown value. Women in rural areas, those living in the Southern region or in Transnistria, and older women were more likely to have abortions free of charge or to pay less than other women. The average cost of a conventional abortion was 25% lower than that of a mini-abortion (38% vs. 48%). A greater percentage of conventional abortions were performed at no charge (38% vs. 24%). Early abortions, the majority of them performed by vacuum aspiration, tend to cost more than abortions performed at higher gestational age. Although the dollar-lei exchange rate did not change significantly in the past five years, there has been a significant increase in the cost of living and a relative decline in the value of the local currency. Thus, abortion payments are also shown by three periods of time. The average abortion cost doubled, from 25 lei in 1992-1993 to 55 lei in 1996- 1997. Only one in four abortions was performed at no charge in the most recent period of time (1996-1997), compared with 36%-39% in 1992-1995. This price increase also corresponds with the gradual increase in the popularity of mini-abortions which are, on average, more costly. The cost of abortions performed in ambulatory units was higher than that of abortions performed in maternities and hospitals (58 lei vs. 51 lei and 40 lei, respectively) but the numbers available are too small for any difference to be statistically significant. 58 59 4.8 Reasons for Abortion Table 4.8 and Figure 4.8 show that 57% of abortions were performed for economic or social reasons (low income, unemployment, fear of losing one's job), 28% for limiting childbearing, 7% for partner-related reasons (in 4% of cases the partner did not want a baby and 3% of women had out-of-wedlock pregnancies or were separated from their partners), 5% for medical reasons (pregnancy was threatening the woman's health), and 3% for eugenic reasons (fetal malformations). Socioeconomic reasons were mentioned slightly more often by rural women, women who reside in Chisinau (where life is more expensive and adequate housing is an increasing problem), women under 35 years of age, women with less than complete secondary education, those with low socioeconomic status, and by Moldovan women. The use of abortion for limiting childbearing was more prevalent in urban areas and was directly correlated with a woman's education and socio- economic status; this reason was also claimed more often by women residing in Transnistria or in the Northern or Southern regions (32-33%), by Russians, Ukrainians and other ethnic groups. 60 61 Partner-related reasons were more common among women who were not married when they got pregnant, and among those who got pregnant for the first time; women with higher levels of education were slightly more likely to report partner's opposition to have another child than women with less than complete secondary education. Health-related reasons were more often reported by rural residents, residents in the Central region (9%), and women of high socio-economic status; they also increased with woman's age. Similarly, the risk of birth defects was mentioned more often by rural women, residents of the Central and Northern regions, and increased with education and socio- economic level. 4.9 Abortion Complications Legally induced abortions are associated with a certain risk of postoperative complications, whose incidence and severity is strongly correlated with age of gestation, parity, woman's age, surgical procedure and operator's skills, type of anesthesia and preexisting pathology (Henshaw, 1990). For example, abortions performed at 7-9 weeks of gestation have significantly fewer complications than those performed between 10 and 14 weeks. Early abortions performed under 7 weeks of pregnancy have slightly higher risk of complications than those performed from 7 to 9 weeks. Abortions performed by vacuum aspirations, with or without cervical dilatation, have fewer complications compared with the classic sharp curettage. First-trimester abortion complication rates from studies performed in developed countries ranged from 0.9 per 100 abortion procedures in the U.S. (Hakim-Elahi E. et al., 1990) to 6.1/100 in Denmark (Heisterberg L. and Kringlebach M., 1989) , but in the absence of an international definition of abortion morbidity, comparisons between countries should be interpreted with caution. Survey estimates 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 Table 4.9.1, 16% of all abortions (including mini-abortions) performed since 1992 were followed by immediate complications (11%) or late sequelae (5%). Urban women and those living in Chisinau or Transnistria were slightly less likely to report postabortion complications. Early complications were slightly more prevalent among women aged 35 or older, and among women with more recent abortions. Of course, women with more recent abortions may be more likely to recall complications. Conventional abortions were followed more often by early complications than mini- abortions but there was no difference in the prevalence of late complications. Noteworthy, about one in four abortions with early complications was associated with late sequelae (at six months or more after the abortion was performed). 62 63 Most of the early complications involved severe or prolonged bleeding (52%) or pelvic infection (22%), with or without fever (26%); about a fifth had an infectious vaginal discharge and less than one percent reported perforations of the uterus (Table 4.9.2). With the exception of uterine perforation, it is difficult to assess how serious the other early complications might have been. An indirect approach to measure their severity is to consider early complications as serious when they required overnight hospitalization or were followed by late complications. As shown previously, 64 almost half of immediate complications (44%) required one or more nights of hospitalization and a fourth were associated with late complications. The pattern of early complications is similar for both types of abortion (conventional or mini-abortion). Most of the abortions with long-term side effects (at six months or later) were associated with menstrual changes: 30% had irregular bleeding, 12% had dysmenorrhea (severe cramping pain just before or during the menstrual period), and 3% had secondary amenorrhea (absence of menses). All these conditions are consistent with pelvic infections and intrauterine adhesions; in fact, 15% of women who had abortions with late complications were diagnosed with pelvic infection. Chronic pelvic pains were reported in 33% of abortions with late complications. Only 3% of late complications were represented by secondary sterility. Because of the small number of late complications reported to be associated with mini-abortions, we cannot show any valid statistical differences in long term side-effects by type of abortion. 4.10 Future Fertility Preferences One of the important factors that health-care providers should consider in their efforts to help couples avoid unintended pregnancies, particularly those unwanted, is fertility expectations, which may vary among different subgroups. The respondents in the MRHS were asked about their intention to have any (more) children and the timing of additional childbearing. The figures presented in Table 4.10 and Figure 4.10.1 reflect patterns of fertility preferences only among married women. Table 4.10 shows the distribution of women currently in union by their fertility preferences, according to the number of living children and their current age. Only 13% of these women said they intend to have a child in the near future (within one year). The figures in the first column indicate that almost two thirds (62%) of women in legal or consensual marriage do not want to have any more children, and 13% want to wait at least three years before having a(nother) child. The intention to have any(more) children decreases rapidly with increasing number of living children after achieving the two-children family size (see also Figure 4.10.2). About 80% of women with two children and more than 90% of women with three or more children do not want any more children. Only 5%, 3%, and 1%, respectively, of these women (with two, three, and four or more children) would like to have another child soon. Conversely, 45% of childless women and 12% of women with one child want to have a child now, whereas 21% want to delay childbearing for one or two years. 65 66 Younger women were much more likely to want more children, compared with older women. The intention to have more children decreased from 88% among the youngest age group to 15% for women aged 35-39 and 7% for women over age 40. However, among those who desire additional children, younger women were more likely than older women (aged 35 and over) to want to wait one or more years to have a child. Between 75% and 80% of 15-24 year-olds, 69% of those aged 25-29, and 53% of 30-34 year-old women want to delay having a child by one or more years, whereas very few women aged 35 or more say they want to delay the next pregnancy by one or more years. These findings are very important for the family planning program, which should consider spacing methods for younger women and long-term or permanent methods for older women. 67 68 CHAPTER V PREGNANCY, DELIVERY, AND MATERNAL HEALTH In Moldova improving the health of mothers and infants is a national priority. Maternal and infant mortality are measures of a nation's health and world-wide indicators of social well-being. As of 1995, the last year for which comparison data were available (WHO, 1997), the Republic of Moldova had the third-highest maternal mortality ratio (41 deaths per 100,000 live births ) among Eastern European countries, after Russia and Romania. As of 1997, the infant mortality rate (20 infant deaths per 1,000 live births) ranked second-highest in Eastern Europe (PRB, 1998) after Romania (22.6 per 1,000). In Moldova, women's access to perinatal care is guaranteed by law and is free of charge (Order No. 396, Moldovan MH, 1995). It consists of three components: preconception care, prenatal care, and postnatal care. Preconception counseling is offered by primary care providers and consists of a wide array of information, including risks associated with pregnancies, health risk factors that can affect the development of the fetus (e.g. tobacco and alcohol), maternal infection (such as rubella, toxoplasma, HIV and other STDs), risks associated with maternal health conditions, and risks associated with genetic conditions. Unfortunately, preconception counseling is offered to young couples prior to marriage, one time only, without any follow-up before they plan to start childbearing. Preconception counseling during routine health care visits is not provided in spite of the essential role the primary care provider could play in modifying women's health behaviors (many healthy behaviors must be in place before pregnancy is recognized) and identifying medical conditions that may require special attention during pregnancy. The use of timely and periodic prenatal care can effectively reduce perinatal mortality and morbidity. The Moldovan Ministry of Health recommends that, during a full-term pregnancy, pregnant women should receive at least 12-14 prenatal visits provided by physicians and 3-4 home visits provided by midwives or nurses. As part of comprehensive prenatal care, health risk assessment should include, in addition to the medical examination, an initial series of laboratory investigations (blood, urine, vaginal bacteriological exams, screening for STDs and isoimmunization Rh) that will be repeated periodically. During postnatal care it is important to assess the health of both the mother and her infant and provide counseling about breast-feeding, nutrition, and family planning. Postnatal care in Moldova is initiated soon after the new mother is discharged from the maternity where she delivered and consists of three visits provided by a midwife: the first visit during the first three days, the second visit during the first two weeks, and the third visit up to 6 weeks after delivery. 69 70 The 1997 MRHS included a module of questions that were administered to women of reproductive age who had had a pregnancy since January 1992. The set of questions concerned maternal and child health issues related to all pregnancies carried to term. The woman was asked if she received prenatal care, when during her pregnancy she initiated the prenatal care, how many prenatal care visits she had, and if she had an ultrasound exam during the prenatal period. She was further asked what information she received during prenatal visits, if she had been smoking or drinking alcohol during pregnancy, if she had any pregnancy complications severe enough to require hospitalization, how long she was in labor, if the baby was delivered vaginally or by Caesarean section, the baby's weight, and if she had any complications during the postnatal period. Additional questions were asked to determine the level of satisfaction with the quality of care provided around the time of delivery, the level of comfort, and the length of stay after she gave birth. If the child was born alive, additional questions were asked to determine breastfeeding initiation, breastfeeding duration and patterns. 5.1 Prenatal Care Early and periodic prenatal care can effectively contribute to the prevention of poor birth outcomes, including maternal and infant mortality and morbidity. Prenatal care includes three major components: risk assessment, treatment and supervision for medical conditions, and health education. This section describes the use of prenatal care for all pregnancies carried to term during the five years prior to the survey. Women were asked in what week they had their first visit for prenatal care and the number of prenatal care visits during their most recent pregnancy resulting in a live birth. They were told not to count a visit that was just for a pregnancy test or just for the delivery. Of the 2,141 pregnancies carried to term, virtually all women (99%) had received some prenatal care, and 73% had received their first prenatal care visit in the first trimester (Table 5.1.1). Approximately 25% of them had their first visit during the 2nd trimester and 1% during the third trimester. The level of some prenatal care varied within narrow limits (between 98% and 100%) but the percentage of infants whose mothers entered prenatal care in the first trimester varied more widely, from a low of 62% to a high of 80%. By residence, women living in urban areas were slightly more likely to start prenatal care earlier (74%) than women in rural areas (72%) but the differences were not significant. Early entry into prenatal care was highest among women living in the North region (76%) and lowest among women in Transnistria (69%). The likelihood of early prenatal care was inversely correlated with women's age at the time of pregnancy outcome: 78% of the youngest women (15-24) and 72% of women aged 25-34 had their first prenatal care visit in the first trimester, but only 62% of women over 34 years of age did so. Early entry into prenatal care increased with mother's education; women who had not completed high school had a lower 71 likelihood of initiating prenatal care early compared with women with a postsecondary education (68% vs. 78%). Among various ethnic groups, Ukrainian women and women of other ethnic background had the highest rates of early prenatal care (77% and 80%, respectively) while Russian women had the lowest rate (69%). Births preceded by two or more previous births (birth order three or higher) had the lowest rate of early prenatal care (70%). Prenatal care should not only start early but also should continue throughout pregnancy according to recommended standards of periodicity (the Moldovan MH recommends 12-14 visits for a full-term pregnancy). Therefore, to assess the adequacy of prenatal care it is necessary to monitor not only the time of first visit but also the number of prenatal care visits once the care has begun (Table 5.1.1). Overall, pregnancies ending in birth between 1992 and 1997 averaged almost 11 prenatal visits, and ranged from no visits to 41 visits. In accordance with MH criteria, less than half of pregnancies had an adequate number of visits (12 or more), while a fifth of women had 10-11 visits (21%), another fifth (21%) had 6-9 visits, and 9% had 1-5 visits. About 3% of respondents stated they "don't remember" the number of prenatal care visits but this percentage was much higher among some subgroups (e.g. 12% among women in Transnistria and 6% among women over 34 years of age). This could be due to selective recall bias as mothers experiencing a more recent birth are more likely to remember the number of prenatal care visits than mothers with a less recent pregnancy. Women who had an adequate number of prenatal visits are generally the same women who started prenatal care early, since the number of visits is correlated with the month of initiation of care. A better way to assess the adequacy of prenatal care is to use the Adequacy of Prenatal Care Utilization Index (APNCU), also known as the Kotelchuck index. This index assesses the adequacy of initiation of prenatal care (month when prenatal care begins) combined with the adequacy of utilization of services (percentage of recommended visits received) once the care has begun; this last component of the index is calculated by comparing actual utilization with the recommended number of visits, adjusted for the length of gestational period and the gestational age at initiation of care. These two dimensions are combined into a single utilization index with four levels: inadequate, intemiediate, adequate or adequate plus. Inadequate utilization is defined as either late prenatal care or less than 50% of recommended visits. The three remaining levels require early initiation of care (by the fourth month of gestation). Intermediate care requires 50%-79% of the recommended number of visits, adequate care requires 80%-109% and adequate plus requires 110% or more of the recommended visits (Kotelchuck M, 1994). By applying this index to data from the MRHS we found that two-thirds of births had received adequate or adequate plus care (Table 5.1.2 and Figure 5.1.1). Women with less than adequate care were more likely to live in rural areas (32%) than in urban areas (23%), to reside in the Central 72 73 region (37%), to be older than 34 years (40%), to have not completed high school (33%), to live in households with low SES (36%), or to have two or more other births (33%). Targeting the groups that did not receive prenatal care in the first trimester or who had fewer than recommended visits can help improve both pregnancy and infant outcomes and help Moldova lower perinatal mortality and morbidity. The principal source of prenatal care is shown in Table 5.1.3. Overall, for most pregnancies the principal source of prenatal care was the women's consultation clinic at the municipal (33%) or raional level (24%). The second source of most prenatal visits was a rural dispensary (28%), and the third source was a "circumscription medical ambulatory", the equivalent of a territorial dispensary in urban areas (15%). Very few women sought prenatal care in the republican center (the Institute of Scientific Research for Maternal and Child Health Care). Generally, in village dispensaries and medical ambulatories, primary care providers and midwives cover most of prenatal care, whereas in women's consultation clinics most care is provided by obstetricians. 74 75 As expected, municipal or raional (also situated in urban areas) women's consultation clinics were the principal source for urban residents (95%), residents of Chisinau (90%) and mostly urban Transnistria (77%), respondents with the highest level of education (70%) and high socioeconomic status (88%). By ethnic background, Moldovan women had the lowest rate of utilization of the prenatal care facilities (49%), whereas Russian women were the most likely users (88%). Village dispensaries represented the first source for women in rural areas (47%), residents of the mostly rural Central, Northern and Southern regions (36-39%), and women with low SES (47%). In Table 5.1.3, the estimate of source of care uses as a denominator only women with pregnancies within the past five years who received any prenatal care (the right side of the table). This concept is slightly different from the prenatal care coverage of a given facility which refers to the care offered to the entire population in need of prenatal care (users and non-users of prenatal care facilities). To estimate the prenatal care coverage of a given facility, the proportion of pregnancies receiving care at a certain place has to be multiplied by the prevalence of prenatal care. For example, if the women's consultation clinics within cities represented the source of most care (33%), their prenatal care coverage is slightly lower because we have to take into account all pregnancies, including those without any care. Thus, the real coverage will be 33.1 x 98.8/100= 32.5% of all pregnancies. 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 behavioral risk factors (e.g. tobacco and alcohol use), medical and genetic risks, and occupational risks, and to provide comprehensive counseling. Counseling should include information about maternal behaviors and exposures that may affect the health of the fetus, nutrition, rest, and early signs and symptoms of pregnancy complications. In addition, approaching the time of delivery, counseling should prepare women for what they will face when giving birth, distribute accurate information regarding labor and delivery, and advice about techniques to reduce the pain and anxiety during labor. Also, counseling about breastfeeding and family planning after birth should be initiated during the prenatal period and reinforced during postpartum care. Table 5.1.4 shows the percentage of pregnancies that received some information about specific educational topics during prenatal care. Overall, between two-thirds and three-fourths of women had received some counseling about specific prenatal care topics. Information about delivery and breastfeeding were the most prevalent (77%), followed by information about nutrition (75%), negative effects of smoking and alcohol (72% and 71%, respectively), information about family planning after birth (65%), information about postnatal care (63%), and early signs of complications during pregnancy (60%). Maternal characteristics that appear to be associated with lower levels of counseling for all topics include older age (over age 34), having at least two prior births before the current pregnancy (birth order of three or more), being unmarried or in consensual union at the time of conception (data not shown), 76 77 attaining prenatal care in the second or third trimester, having less than six prenatal visits, and receiving most of the prenatal visits at a raional consultation clinic. Ultrasound imaging has been increasingly used in perinatal care but debate still exists about routine ultrasound screening. Survey data do not allow us to differentiate between use for selected specific indications (e.g. confirmation of gestational age, assessment of fetal viability, fetal malformations, fetal growth, fetal presentation, and multiple pregnancy, examination of the placenta, and assessment of amniotic fluid) or for routine screening, either during early pregnancy (16-20 weeks) or in late pregnancy (after 20 weeks). Table 5.1.5 and Figure 5.1.2 show the prevalence of ultrasound exams during pregnancies that ended between 1992 and 1997. Overall, three out of four pregnancies had had at least one ultrasound exam. Maternal characteristics associated with higher levels of ultrasound exams include: urban residence (86%). residence in Chisinau (93%), high level of education (79%). high 78 79 SES (87%), having the first birth or second (79%), and having most of prenatal visits in a municipal women's consultation clinic (88%). Lower prevalence of ultrasound exams was associated with rural residence (68%), living in Transnistria (66%), low SES (66%), and having most prenatal care in a village dispensary or circumscriptional medical ambulatory (67% and 64%, respectively). About two-thirds of exams were performed for the first time in late pregnancy, suggesting the use of ultrasound for specific indications rather than for screening (the main reason for starting screening in late pregnancy is to detect growth-retarded fetuses who may benefit from caesarian delivery). However, women in urban areas or Chisinau, those with high educational attainment or high SES, those who started prenatal care during the first trimester, and those whose source of prenatal care was a municipal women's consultation clinic were slightly more likely than other women to have their first ultrasound exam during early pregnancy. 5.2 Intrapartum Care All births should occur in medical facilities where adequately trained personnel can monitor the progress of labor and delivery. According to vital records data, virtually all deliveries in Moldova take place in maternities or ambulatory units with inpatient obstetrical care ("birth houses"). Births delivered outside medical facilities are rare (less than 1.5% of all births). Survey data confirmed that very few deliveries occur outside the hospital (Table 5.2.1). The majority of women gave birth in a maternity or a hospital obstetrical ward (77%). Almost all other women delivered in birth houses and only 1% delivered at home. Hospital births were the most prevalent regardless of maternal characteristics. The only notable exception was found among women living in Transnistria, who were most likely to deliver in birth houses (84%). Home deliveries were rare, however, women with low levels of education or low SES were slightly more likely to deliver at home (2% and 3% respectively). Four percent of low birth weight babies were delivered at home. In Moldova, the overall prevalence of Caesarean deliveries among all deliveries that occurred between 1992 and 1997 was 6% (not shown). The Caesarean section (C-section) rate varies considerably among countries, from about 5% to more than 20% of all deliveries. The optimal rate is not known, but little improvement in birth outcomes has been demonstrated if the rate was higher than 7%. In addition to unequivocal obstetrical indications, C-section is often performed in less clear situations (e.g prolonged labor), and often if a previous C-section was performed, which is rarely an adequate indication by itself. Table 5.2.2 presents the percentage of most recent births delivered by C-section. The same overall rate of 6% of births were delivered by C-scction. Women giving birth in Chisinau were almost twice as likely to have a Caesarean delivery than women in 80 81 82 other regions. The lowest rates were reported by women in Transnistria and the Southern region (4%). Women aged 35 years or older reported rates (11%) almost twice as high as younger women (6-7%). The C-section rate increased directly with socio-economic status, suggesting that financial considerations. may sometimes be more important than obstetrical indications for Caesarean delivery. As expected, women who were hospitalized for various reasons prior to delivery (see Table 5.6.3 on page 101) were more likely to deliver C-section than uncomplicated pregnancies (11% vs. 4%). Apparently, prolonged labor is not a common indication for C-section in Moldova. Births with labor duration of more than 24 hours (more than 18 hours for multiparas) had the same rate of delivery by C-section as births with shorter duration of labor. Almost half of women with Caesarean deliveries had the intervention performed prior to beginning of labor. The MRHS also included questions about respondents' experiences and opinions regarding services received at the time of the most recent birth. Women were asked about the medical facility in which they had their most recent delivery, including: hygiene, comfort, crowdedness, permission for visitation, attentiveness of staff, and perceived competence of health professionals (table 5.2.3). Overall, each of the six characteristics was rated as "good" by between 30% and 55% of respondents, but for some selected subgroups of women the satisfaction with the medical facilities was much lower (from 22% to 40%). The aspect of care about which women were most satisfied was the competence and attentiveness of staff. Dissatisfaction with services (percent who rated the facility as "poor") ranged from 7% for competence of health professionals to 34% for visitation 83 permission. Visitation is one area that greatly affects satisfaction with services and could most easily be improved. Between 14% and 18% of respondents were clearly not satisfied with the crowdedness of the facility and its lack of comfort, respectively. Generally, the poor rating given to each characteristic was more prevalent among urban residents, women living in Chisinau, women with high socio-economic status and women who delivered their first child. Each woman's experience during her last birth was further evaluated based on two additional indicators: how many women had to share the same room in the facility where the most recent birth took place and how many days the woman spent in the medical facility after delivery. Both indicators had a great impact on the respondents' rating of perinatal care facilities. As shown in Figure 5.2, women who were placed in rooms of six or more persons were between 1.5-2 times more likely to express dissatisfaction about the facility's hygiene, comfort, or crowdedness (women who were giving a "poor" rating to these facility characteristics). Table 5.2.4 summarizes the crowded conditions that respondents experienced during the time of their most recent birth. Overall, the majority of women were in rooms of four or more persons 84 85 86 (76%), including 25% of women who were placed in rooms of six or more persons. Women in rural areas (27%), women with low socio-economic level (29%),and those who delivered low birth weight babies were more likely to be placed after delivery in rooms of six or more women. Conversely, women who lived in Chisinau (26%), those with a post-secondary education (26%), and those with high SES (32%) were more likely to be placed in rooms of 2-3 persons. Table 5.2.5 shows the length of stay after the most recent delivery. The majority of women were discharged after 5 days (40%) or 6-7 days (30%). Very few women went home within the first four days after delivery (11%) but almost a fifth had to stay eight or more days. Women in rural areas spent, on average, more time in hospital after delivery (not shown) and were slightly more likely than urban women to be hospitalized for eight days or more (20% vs. 17%). Similarly, residents of the mostly rural Central and Northern regions were more likely to be discharged after eight or more days (25% and 24%, respectively). As expected, women with low birth weight babies, women with early postpartum complications, and those with C-sections had much longer stays compared with other new mothers. 5.3 Postnatal Care The postnatal period is a critical opportunity to evaluate the physical and psychosocial health of a new mother and her infant, to detect and treat postpartum complications, and to provide the counseling and support needed to address any specific problems related to child care and family planning. The survey provided information about the use of postnatal care and the content of postnatal counseling (Table 5.3). Overall, postnatal care was not utilized as often as prenatal care (74% vs. 98%), in spite of the official recommendations. Surprisingly, its use was slightly higher among rural residents than among urban women (77% vs. 69%). Furthermore, residents of Transnistria had the lowest use of postnatal care (59%) whereas the North region reported the highest use (79%). Postnatal care utilization was lower among women older than 34 years (69%) but was not influenced by birth order and did not vary significantly with education or SES levels. The presence of any complications soon after delivery was associated with slightly higher rates of postnatal care use (78% vs. 73%). Almost three-fourths of all women who received postnatal visits were counseled about child care, child immunization, breastfeeding and breast care (71%). In addition, 69% of women received information about nutrition needs for them and their infants during the postnatal period. Counseling about planning for future pregnancies and methods of birth control was the lowest (58%). Maternal characteristics associated with less health advice given during postnatal care included: urban residence, residence in Transnistria, and older age (35-44 years). 87 88 5.4 Breastfeeding Breast milk is the most complete food an infant can receive during the first few months of life. Breastfeeding is associated with a wide range of benefits for infant health, growth, immunity, and development. These benefits include decreased incidence and severity of diarrhea (Dewey KG et al., 1995; Popkin BM et al.,1990), respiratory and ear infections (Kovar MG et al, 1984; Howie PW et al., 1990), longer birth intervals (by delaying the return of ovulation), and reduced cost to the family. In addition, breastfeeding has been shown to improve maternal health by reducing postpartum bleeding (Chua S et al., 1990), allowing an earlier return to prepregnancy weight (Dewey et al., 1993), and reducing the risks of premenopausal breast cancer (Newcomb PA et al., 1994) and osteoporosis. The 1997 MRHS included questions about breastfeeding patterns and duration. As shown in Table 5.4.1, virtually all babies (93%) born during the past five years were breastfed at least for short periods of time. The percentage of babies ever breastfed varies little by selected characteristics. Rates of breastfeeding were slightly lower among women older than 34 years of age at the time of delivery (87%), and among women without any prenatal care (82%). Babies without any postnatal care were less likely than those with postnatal care to have been breastfed (89% vs. 95%). Early initiation of breastfeeding is beneficial for the health of both the infant and the mother. If the mother initiates breastfeeding immediately after she gives birth, the nipple stimulation during suckling triggers the release of oxytocin and uterine contractions that help reduce postpartum bleeding. Sedatives and analgesics given during labor alter the behavior of newborns and can compromise the essential role of the baby in the initiation of lactation. Not surprisingly, children who were delivered by Caesarean section had a lower rate of breastfeeding than those delivered vaginally (86% vs. 94%). Other practices may compromise the initiation of lactation as well. Routine administration of silver nitrate eye drops in the immediate postnatal period or the early separation of babies from their mothers, either because of old-fashioned hospital regulations or because the infants need treatment, have also been shown to reduce the likelihood of breastfeeding initiation. According to WHO recommendations adopted by the Moldovan Ministry of Health, early suckling (within the first hour post-delivery) should be promoted following all spontaneous deliveries. Table 5.4.2 and Figure 5.4.1 show the time passed between delivery and initiation of breastfeeding. Of infants who were breastfed, only 8% began breastfeeding during the first hour after birth. The majority of children began breastfeeding within the first or second day of life (56% and 17%, respectively). However, one fifth of babies began breastfeeding only after 48 hours. 89 90 91 Breastfeeding initiation within the first hour was slightly more prevalent among women living in Chisinau or the South region (10%) whereas residents of Transnistria almost never initiated breastfeeding so early (1%). In terms of babies' characteristics, low birth weight, prematurity (not shown), and Caesarean delivery substantially reduced the likelihood of early breastfeeding. For these infants, breastfeeding is more likely to be initiated after two days, if ever. Indeed, only 60% of low birth weight babies and preterm babies and 85% of babies delivered by Caesarean section had ever been breastfed. Table 5.4.3 and Figure 5.4.2 show the age of infants at the time of weaning (in months). Overall, about a third of infants born within the five years prior to the survey were breastfed for less than five months. Thirty-one percent were breastfed for 5-11 months and 36% were breastfed for more than a year, including a small proportion (1%) who were weaned after two or more years. 92 93 Maternal characteristics associated with breastfeeding for at least one year include: rural residence (41% of rural women compared with only 28% of urban women); residence in the South (45%) or Central region (42%); maternal age at delivery of more than 34 years (45%); low socio- economic status (40%); and multiparity (40%). The mean duration of breastfeeding was 8.5 months (Table 5.4.4). For most of this time, however, breastfeeding was only partial. An infant is considered to be exclusively breastfed if he/she receives only breast milk. The infant is considered almost exclusively or predominantly breastfed if he/she receives water or other liquids (excepting non-breast milk) in addition to breast milk. Children with exclusive or almost exclusive breastfeeding are considered to be fully breastfed (Labbok MH and Krasovec K., 1990). Unfortunately, survey data do not allow for estimates of exclusive breastfeeding. For all births, the mean duration of full breastfeeding was 3.6 months. The duration of full breastfeeding did not vary greatly by maternal characteristics. 94 95 5.5 Smoking and Drinking During Pregnancy The use of tobacco and alcohol during pregnancy are major risk factors for poor pregnancy outcomes. Smoking during pregnancy has been linked to low birth weight (LBW) babies, preterm deliveries, sudden infant death syndrome (SIDS), and respiratory problems in newborns. The damaging effects of alcohol use during pregnancy include fetal growth retardation, mental retardation, physical abnormalities, especially dysmorphic facial features, and altered neonatal behaviors. Developmental abnormalities occur in approximately 35-40% of infants born to alcoholic mothers and are associated with consumption of at least two drinks per day (Coles CD, 1993). Overall, almost 7% of births in the five years preceding the survey occurred to mothers who were smokers at the time they found out about their pregnancies. Of those, only about a fourth continued to smoke during pregnancy (Table 5.5). The proportion of women who smoked prior to getting pregnant was about four times higher in urban areas than in rural areas (12% vs. 3%). Women residing in Chisinau and Transnistria were much more likely to smoke prior and during pregnancy compared with women from other regions. The proportion of smoking mothers was directly correlated with socio-economic status. Women with high SES reported levels of smoking before and during the pregnancy several times higher than those with middle or low SES. The highest prevalence of tobacco use prior or during pregnancies was reported by Russian women (20% and 5%, respectively). The same maternal characteristics were associated with a higher level of tobacco use during pregnancy. Smoking during pregnancy was highest among women with a high socioeconomic status (5%) and Russian women (5%). Drinking during pregnancy was much more prevalent than smoking (30%). However, only about half of women who drank while pregnant were drinking daily or several times per week (not shown). Women in Transnistria (41%), women older than 34 years (43%), and women with two or more previous births (40%) were more likely to report drinking alcohol during pregnancy. 5.6 Pregnancy and Postpartum Complications As shown in Table 5.6.1, almost all women (98.5%) had routine measurement of their blood pressure during pregnancy and 12% were identified as having high blood pressure (HBP). One in twenty (5%) pregnant women were hospitalized due to HBP. The prevalence of HBP was noticeably higher among women 35-44 years of age (24%) and 13% of older women were hospitalized due to 96 97 98 HBP. A lower prevalence of HBP was reported in Transnistria (8%). Poor birth outcomes during the five years preceding the survey are reported in Table 5.6.2. Of all births, 7.6 per 1,000 were stillbirths. This figure is similar to official statistics, which report rates of 7.8 per 1,000 in 1992 and 7.5 per 1,000 in 1996. The stillbirth rate was higher among women living in urban areas (10.7 per 1,000), residents of Chisinau (11.1/1,000 births), among women aged 35-44 at the time of delivery, (16.5/1,000), among Ukrainian women and women of other ethnic backgrounds (20.9 and 13.7 per 1,000 births, respectively), and among first births (10.1 per 1,000) or births of rank three or higher (13.7/1,000). As expected, complicated pregnancies that required hospitalization were more likely to have poor birth outcomes, including a higher stillbirth rate (12.1/1,000). Consistent with data from the literature, women who smoked during pregnancy had a much higher risk of stillbirth (26.3/1,000). The incidence of low birth weight (under 2,500 grams) was 5.4% among all births in the same period of time. Higher rates of low birth weight (LBW) were reported by women aged 35-44 (12%), women who were hospitalized for pregnancy complications (8%), and women who smoked during pregnancy (8%). Since a major cause of LBW is prematurity, the same groups of women were more likely to report preterm births. Overall, almost one in three women (30%) were hospitalized during pregnancy. The proportion of women who required hospitalization during pregnancy was slightly higher in urban areas than in rural areas (32% vs. 28%) and increased directly with age, education and socio- economic status (data not shown). As shown in Table 5.6.3, hospitalization associated with pregnancy complications, as reported by respondents, ranged from less than one percent to 12%. The highest hospitalization rate was for the risk of miscarriage, followed by the risk of preterm labor (9%). Hospitalizations for the risk of miscarriage were higher for younger women, higher socioeconomic women, the first birth and women who had their first prenatal visit during the first trimester. The risk of preterm labor resulting in hospitalization was highest for residents of Chisinau and the Central Region, who are more likely to be Moldovan. In general, hospitalization rates for most complications were lower for rural women, residents of Transnistria and women with third or higher births. Postpartum complications reported by the sampled women are shown in Table 5.6.4. Reported complications ranged from 7% with high fever to 2% with a breast infection. High fever was reported most often by older women (12%), those that reported pregnancy complications (17%) and those who had a Caesarean delivery (23%). Women with a Caesarean delivery were also more likely to report severe uterine pain and infection of the surgical wound. 99 100 101 102 CHAPTER VI KNOWLEDGE OF CONTRACEPTION Data from the survey provide the first nationally representative information about family planning awareness and can constitute the baseline for the information-education-communication (IEC) efforts launched recently as a component of the family planning program. Two major goals of the IEC activities are to heighten contraceptive awareness and knowledge among reproductive age women, which in turn should increase the demand for family planning services, and to indirectly improve the family planning system, since better-informed clients will make better choices that will ensure diversified and comprehensive services that are client friendly. An important objective of the MRHS was to explore the level of knowledge of family planning methods and their source of supply among women of reproductive age in the aftermath of intensified IEC efforts. Respondents were asked, in reference to 10 modern and traditional contraceptive methods, if they have ever heard about each, from whom, if they know how they are used, and if they know where they could be obtained. 6.1 Contraceptive Awareness and Knowledge of Use Table 6.1.1 summarizes the findings on contraceptive awareness by residence and region for women of reproductive age. Virtually all women (99%) have heard of at least one modern method and most of them have heard of a traditional method (88%). The best known modern methods were the IUD and the condom, known by almost all women (97%), followed by withdrawal (84%). Contraceptive female sterilization (tubal ligation) and pills were known by about two-thirds of women (68% and 66%, respectively). The least known modern methods were those that are seldomly used in Moldova (vasectomy, injectables, Norplant, and spermicides). Although most women have heard about withdrawal (84%), only about two-thirds have heard about the calendar method (69%). The level of overall awareness of either modern or traditional methods did not vary significantly by residence or region. However, some urban-rural and regional differences were notable in the awareness about specific contraceptive methods. For example, the awareness of IUD and condom is 2 and 6 percentage points higher among urban residents than among rural residents and the gap becomes larger for the calendar method (80% vs. 56%) and for some lesser known 103 methods (vasectomy and spermicides). Particularly notable is the difference in pill awareness (75% in urban areas vs. 56% in rural areas), in spite of the substantial influx of oral contraceptives donated in the last couple of years. For almost all methods, the level of awareness in Chisinau is higher than in other regions, followed by Transnistria and the Southern region. In Transnistria, the awareness of oral contraceptives was the highest in the country (80%), but awareness of other hormonal methods, contraceptive sterilization (tubal ligation and vasectomy), and spermicides was significantly lower than the country average. 104 Table 6.1.2 shows the level of contraceptive awareness by age and by marital status. Although overall awareness of modern methods was equally high and did not vary with the respondent's age, some methods were less known by the youngest respondents. Conversely, the awareness of traditional methods was considerably lower among the youngest women (71% vs. 97% and 96%, respectively). Women aged 15-24 were less likely to have heard of both withdrawal and the calendar method (64% and 56%, respectively) than women aged 25-34 (96% and 77%) or those aged 35-44 (95% and 75%). For women aged 15-24, the awareness of condoms was slightly higher 105 than of the IUD (97% vs. 93%) and pill awareness ranked third, whereas only 48% have heard of tubal ligation. For older women, the best-known modern methods were the IUD, condom, and tubal ligation, known by 99%, 97%, and 78% of women, respectively. Virtually all currently married or cohabitating women (women in union) as well as previously married women have heard of at least one modern method and at least one traditional method. With the exception of never-married women, whose awareness of traditional methods is much lower than that of modern methods (58% vs. 98%), knowledge of modern or traditional methods was equally high. However, awareness of some modern methods was lower among never- married than among ever-married respondents. Since marital status is directly correlated with age and never-married women were more likely to be young, the pattern of knowledge of specific methods among unmarried women resembles that for younger women, with higher awareness of condom (96%) and lower awareness of IUD (88%) and tubal ligation (38%). Table 6.1.3 shows that the overall level of awareness of modern methods is not significantly different for better-educated women, but the awareness for specific methods is higher among women with secondary or higher education. Particularly notable: the awareness of tubal ligation and oral contraceptives increased directly with education from 56% and 50%, respectively, among women with less than ten years of schooling to 79% and 87%, respectively, among women with university education. Similarly, the awareness of the least known methods (vasectomy, injectables, and spermicides) is considerably higher among better-educated women. The only method widely unknown even among the best educated women was Norplant. The overall awareness of traditional methods is positively correlated with education. Women who have not completed secondary education were significantly less likely to have heard of traditional methods, particularly the calendar method. Knowledge of this method ranged from 47% among lesser educated women to 84% and 91% among women with college or postgraduate education, respectively. Very often the awareness of contraceptive methods is used interchangeably with knowledge of methods. A major criticism of this practice is that it may overstate the level of contraceptive knowledge without exploring the extent of the information possessed by those who can identify contraceptive methods. To better document the level of contraceptive knowledge in Moldova, the questions asked in the MRHS to explore family planning awareness included an additional question about knowledge of how each method or procedure is used. 106 As seen in Table 6.1.4 and Figure 6.1, the knowledge of use of at least one modern or one traditional method was lower than awareness (90% vs. 99% and 79% vs. 88%, respectively). For the most widely known modem contraceptive methods (IUD, condom, tubal ligation, and pill), there is a serious gap between awareness of the method and knowledge of how it can be used. Although awareness of the IUD and condom were universal, only about two in three women said they actually knew how these methods are used. Additionally, though almost two in three women have heard of the pill or tubal ligation, only 31% and 39%, respectively, know how these methods are used. A similar gap in knowledge is obvious for injectables and spermicides, narrowing the proportion of women who may potentially be able to start using these methods to only 12%. 107 The gap between awareness and knowledge of use is also present for the calendar method, and, to a lesser extent for withdrawal. The difference between awareness and knowledge of use narrows with the increased level of education. For example, the proportion of women who do not know how the IUD or the condom are used decreases from 42% and 48%, respectively, among less educated women, to less than 20% among women with university education. The proportion who don't know how tubal ligation works decreases from 71% to 48% and that of women who don't know how to use the pill decreases from 83% to 46%. 108 6.2 Knowledge About Contraceptive Effectiveness Correct information about contraceptive effectiveness can greatly influence a couple's decision on how to protect against unintended pregnancies. It is not realistic to expect that individuals will make the right decision if they have gaps in their knowledge about all possible contraceptives available and if there is lack of adequate access to comprehensive family planning services. Women's lack of knowledge about contraception is an indirect indicator of the failure of adequate counseling. The survey included a series of questions in which each respondent was asked to indicate whether specific contraceptive methods (shown on a card) have high, medium, or low effectiveness when used consistently and correctly. Answers to these questions are presented in Table 6.2.1. 109 Methods are listed in descending order of effectiveness (Hatcher R. et al., 1998). This ranking is based on studies of unintended pregnancies among users of various family planning methods in the first 12 months of using that method (method failure). According to these reports, Norplant implants and vasectomy (whose specific effectiveness was not explored in the survey because it largely unavailable in Moldova) are the most effective methods, with a rate of failure at one year of use of only 0.1 pregnancies per 100 women. They are followed by Depo-Provera, female sterilization, and IUD, with rates of failure between 0.3 to 0.6 pregnancies per 100 women. Combined oral contraceptives have failure rates comparable with Norplant and vasectomy (0.1 pregnancies per 100 women) when used correctly and consistently, but their actual failure rate, as commonly used, is much higher (6-8 pregnancies per 100 women). For this reason we listed oral contraceptives after the IUD, although its effectiveness during ideal use is somewhat higher than for the IUD. Condoms and other barrier methods are considered to be of moderate effectiveness, with rates of failure of 3- 6% during correct use and 14-26% as commonly used. The calendar method can be moderately effective if used correctly. Lastly, withdrawal was listed as less effective than all other methods. 110 Overall, only female sterilization and the IUD were correctly recognized as highly effective by a majority of women (60% and 55%). Although the respondents' knowledge about the IUD's effectiveness for preventing pregnancy was far more accurate than knowledge of other methods, almost one in three women believed the method is only moderately reliable and 8% did not know if it is reliable or not; knowledge about tubal ligation was lacking for almost a third of respondents (32% did not know if it is effective or not). Other very effective methods (Norplant and Depo- Provera) were almost unknown (as also previously shown in Table 6.1.1). Lack of knowledge was also evident in assessing contraceptive effectiveness of spermicides (60% did not know how to rank this method), and oral contraception (37% could not rank this method). As shown in Figure 6.2, slightly less than two-thirds of respondents correctly identified female sterilization (tubal ligation) as having high contraceptive effectiveness; about half knew that the IUD is highly effective, and a fifth knew that oral contraception is highly effective. The condom 111 was disproportionately believed to be highly effective in preventing pregnancy (43%). A possible explanation for this confusion may be found in greater levels of media coverage about the contraceptive benefits of condoms without comparable coverage about other modern methods. Additionally, since educational campaigns about condoms have emphasized equally its contraceptive benefits and its role in preventing STDs, some respondents may have overestimated its protection against pregnancy influenced by the condom's effectiveness against STD transmission. Calendar and withdrawal were correctly identified as less effective methods by 33- 40% of respondents but almost a third of women (27-29%) considered these methods moderately effective and 9-18% of women thought they are highly effective. Table 6.2.2 presents percentages of women who correctly identified method-specific effectiveness, by selected characteristics. Norplant implants, Depo-Provera, and spermicides were not included since the majority of women did not have enough knowledge to make estimates of their effectiveness. Knowledge about tubal ligation being highly effective was associated with urban residence, older age (over 24 years), ever being married, and having a post-secondary education or a high SES. Virtually all women with tubal ligation (92%) had correctly identified their method as highly effective whereas women in Transnistria (48%) and young adults (47%) were the least likely to have this knowledge. Ukrainian women were slightly more likely to identify tubal ligation whereas Russian women were the least likely to consider female sterilization highly effective. Similarly, the same groups of women had knowledge of the IUD's high effectiveness. However, the highest proportions of women who said that IUD is highly effective were Transnistrians (70%), women of Russian descent (64%) and the IUD users (85%). The effectiveness of the pill was the least likely to be correctly recognized. Only 22% of women knew that when pills are taken correctly they are highly effective; this proportion increased among urban women, including Chisinau residents, women aged 25-34, highly educated women and women with high SES, Russian women, and pill users (82%). Condoms were more likely to be correctly classified by women in urban areas (38%), Transnistrian residents (47%), older women, ever-married women, women with a post-secondary education (40%), Russian and Ukrainian women (40%), and women using methods more effective than condoms (condom users were slightly overconfident in condoms' protection against pregnancy). The calendar method, seldom used in Moldova (see Chapter VIII), was rarely recognized as having a moderate effectiveness when it is used correctly and consistently (29%). More women distrust the calendar as being protective against pregnancy, or they do not know how effective it may be. Withdrawal was accurately known as a 112 113 less effective method by 40% of respondents, more so if they were living in urban areas, in the Northern region or in Transnistria, if they were aged 25-34, better educated, and of Russian or other ethnic background. Never-married women, low educated women, those with low SES. and traditional method users were the least likely to know that withdrawal has low effectiveness. 6.3 Knowledge about Condoms' Effectiveness in Preventing STDs Used correctly, condoms can help prevent both pregnancy and sexually transmitted diseases (STDs). Although the method-specific contraceptive effectiveness is lower than for other modern methods, condoms are highly effective in preventing STDs. To be highly effective, they must be used at each intercourse. Even one unprotected intercourse with an infected partner has a risk of STD transmission, ranging from 1% for HIV to 30% for genital herpes, 40% for chlamydia, and 50% for gonorrhea (Harlap S. Et al., 1991). Studies on all users, including some people who used condoms inconsistently or incorrectly, show that condoms reduce by half the risk of getting HIV and by a third the risk of other STDs (gonorrhea, chlamydia, trichomoniasis). However, consistent and correct users have a minimal risk of contracting STDs, including HIV. In addition to respondents' knowledge about the condom's contraceptive effectiveness, the survey investigated their knowledge about the condom's role in protection against STD transmission. Table 6.3 shows the percentage distribution of women by their knowledge about the condom's effectiveness in protection against STD transmission. Overall, three-fourths of respondents believed that condoms are effective in preventing STDs, including 26% who said they are very effective. However, 3% of women said that condoms are not at all effective, and 12% did not have enough knowledge to assess whether they are effective or not. Rural residence, older age (35-44 years), primary education, low socioeconomic status, and lack of experience with condoms and pills were associated with lack of knowledge or beliefs about the efficacy of condoms in protecting against STDs. As may be expected, the perceived effectiveness of condoms in preventing STDs was the highest among women who were currently using condoms (more than 90%). 114 115 6.4 Knowledge About Advantages and Disadvantages of Using the Pill and IUD Since the IUD is the most common modem method used in Moldova and the national family planning program made the increase in pill use a priority, the survey explored in more detail women's knowledge about these methods by asking all respondents if they agreed or disagreed with specific statements about advantages and disadvantages of using the pill or the IUD. Another major reason for low prevalence of pill use, in addition to lack of knowledge about method effectiveness, is women's lack of awareness about the health benefits of oral contraception, which include lower risks of ovarian and endometrial cancers, benign breast disease, pelvic inflammatory disease, ectopic pregnancy, iron-deficiency anemia, and dysmenorrhea (painful menses); also, pill use is associated with a lower incidence of premenstrual syndrome, lighter and more regular periods, and fewer days of bleeding. 116 117 Knowledge about selected advantages of using oral contraception is shown in Figure 6.4.1 and Table 6.4.1. Only about half of respondents agreed that contraceptive pills are easy to use or easy to obtain. Even fewer women (36%) agreed that use of oral contraceptives increase sexual spontaneity (by not interfering with sexual intercourse and removing the worry about pregnancy). Only 30% of women knew that oral contraceptives can make the menstrual period more regular, lighter and shorter, and could relieve painful cramps before or during menstruation. Urban women, those residing in Transnistria and Chisinau, married women, and women who ever used the pill are more likely to agree with advantages shown in Table 6.4.1. Knowledge about certain disadvantages associated with the use of the pill and IUD are shown in Figure 6.4.2 and Tables 6.4.2 and 6.4.3. About half of women think that the pill is too expensive and 41% say it is too difficult to remember to take the pill every day. Ten percent agreed that pills reduce sexual drive. However, as it was with the case of advantages of oral contraceptives, between 40-50% of women did not know how to answer the questions about the pill's disadvantages. With that many women not knowing either the benefits or the disadvantages 118 associated with the use of pills, it is hard to interpret the answers of those who ventured a response. The profile of women agreeing to specified disadvantages of the pill was similar to those agreeing with its advantages. Almost two-thirds of women (64%), whether they have used an 1UD or not, agree that the IUD is associated with increased menstrual pain. About half (53%) agree that the IUD can cause longer and heavier menstrual periods and 41% agree that using the IUD is stressful because of the fear of having "a foreign device" in the body. Only 14% said it was too expensive, a much lower proportion than the 42% of respondents saying the pill was too expensive. Married women and women older than 25 were more likely to agree with the specified disadvantages of the IUD. All respondents who know or have heard of the pill or the IUD were also asked if a woman's risk for certain health conditions would be increased, decreased, or not affected if she uses these methods. Results are shown in Table 6.4.4. On the left side of the table, the health conditions are listed in three groups, in the order of which they may be affected by IUD use (top of the table) and pill use (bottom). For example, IUD use increases the risk of longer and heavier periods, genital infections (in women with recent STDs or multiple sex partners), and pelvic inflammatory disease (PID), which can lead to infertility. The risk of ectopic pregnancy is actually lower among IUD users than among women who do not use any contraception. The IUD does not influence the risk of cancer. Use of oral contraceptives increases the risk of weight gain, may cause headaches and mood changes, including depression, and causes a small risk of cardiovascular disease, including vein thrombosis. By stopping ovulation, the pill actually helps prevent ectopic pregnancies. Taking all reproductive cancers in one group, those that are prevented (ovarian and endometrial cancer) and those that are associated with the use of oral contraceptives (breast and cervical cancer), researchers estimate that for every 100,000 women, 44 fewer pill users have the risk to develop cancer during their lifetimes, compared with non-pill users (Cocker et al., 1993). The risks of sexually transmitted diseases and subsequent infertility are not affected by pill use and fertility returns soon after stopping use. For IUD use, 73%-76% of women think the IUD increases the risk of prolonged menstrual bleeding, genital infections, and abdominal pains. Approximately half believed it will increase the risk of infertility and ectopic pregnancy; about a fourth of women did not have enough knowledge about the IUD to venture an opinion. Finally, 61% said the IUD increases the risk of cancer, although there is no evidence of this in the literature. Opinions on pill use are shown in the bottom panel of Table 6.4.4. Two-thirds of women agree that the pill increases the risk of gaining weight. Another 39%-45% said that the pill is associated with greater risk of depression and headaches. Between 23% and 29% agree with a higher risk of the other health conditions shown. About one- third or more of women do not know enough about the pill to venture an opinion on health risks for all but one condition shown. 119 120 121 122 CHAPTER VII ATTITUDES AND OPINIONS ABOUT CONTRACEPTION Thanks to recent efforts by a number of international donors and the Moldovan Ministry of Health, both the access to a wider range of modern methods and the delivery of adequate information on modern contraception seem to be improving. The previous chapter has shown that Moldovan women, despite their relatively high awareness of various contraceptive methods, have a lower level of knowledge about how methods are used, how effective these methods are, and the health advantages and disadvantages of using intrauterine devices and pills. As such, it is important to know in more detail how their level of knowledge influences their attitudes and opinions about contraception and ultimately their contraceptive practices. The MRHS included a series of questions to explore women's attitudes and opinions on several aspects of reproduction and contraception, including perceptions of their role in decision- making about sex, family planning, and fertility. In this chapter we present data on opinions about the best methods to prevent pregnancy, opinions about the safety of various family planning methods, and who they think would be the best source of information on contraception. 7.1 Opinions About the Best Method to Prevent Pregnancy Opinions about the best method to prevent pregnancy were assessed among all respondents by showing them cards which listed all contraceptive methods and recording their answers on the questionnaires. Although opinions about the best method to prevent unintended pregnancy differed by respondents` background characteristics (Table 7.1 and Figure 7.1), most women believed that modern methods, particularly the IUD (48%), the condom (15%), and female contraceptive sterilization (10%), would be the best contraceptive to prevent pregnancy. Interestingly, traditional methods, withdrawal and the calendar method, were believed to be the best method to prevent pregnancy by 13% of women, in spite of their knowledge of low use- effectiveness associated with these methods (see Chapter VI). Only 6% of women ranked the pill as the best method, consistent with their low knowledge of how this method is used and how effective it is when used consistently and correctly. A very small percentage of women (2%) considered that no method of contraception is good enough to prevent pregnancy and about 7% of women had no opinion. 123 124 Opinions about the best contraceptive were heavily influenced by women's background characteristics (Table 7.1). Urban women were slightly more likely than rural women to name a modern method as the best contraceptive whereas almost twice as many rural women said that a traditional method would provide the best pregnancy protection. Women in Transnistria overwhelmingly said that the IUD is the best method (64%), whereas residents of Chisinau were slightly more likely to report, after the IUD, that either condoms (21%), tubal ligation (13%) or the pill (8%) would be the best contraceptive methods. More women in the Northern region (16%) would name traditional methods as the best contraceptive. Opinions on which specific modern method is the best in preventing pregnancy were related to the respondents' age. Young adults were more likely than older women to believe that, after the IUD, the best method to prevent pregnancy is the condom (27% vs. 10% among women aged 25-34 and 6% among 35-44 year-olds), whereas 25-34 year olds and 35-44 year-olds held more trust in the IUD (54-56%) as being the best method. Beliefs that traditional methods are 125 the best methods increased directly with the increase in respondents' age, from 10% among young adults to 16% among women aged 35 or over. It is important to emphasize that a sizable proportion of young adults (12%) did not have enough knowledge to express any opinion about the best method of contraception. Reflecting their experience with contraception, these same differences were found between ever and never married women. Ever married women were more likely to rank the IUD as the most effective method to prevent pregnancy (55%), followed by traditional methods (14%) and female contraceptive sterilization (11%), whereas never married women were more likely to think that condoms are the most effective (34%), followed by the IUD (24%) and the pill (9%). Again, it is important to note that 17% of never married women did not know what would be the best method of contraception. Differences in opinions about the efficacy of contraceptive methods were also influenced by the respondents' level of education and socio-economic status. Highly educated women were twice as likely as less educated women to consider tubal ligation as the best method, after the IUD and the condom, and slightly more likely to prefer the pill. Similarly, women with high SES were more in favor of tubal ligation (their third best method) and twice less likely than women with low SES to endorse traditional methods as the best methods to prevent pregnancy (9% vs. 18%). Relatively high proportions of women (12%) with the lowest education level were not able to say what was, in their opinion, the best method of contraception. Conversely, among women with the highest educational attainment, almost all (97%) had an opinion. Compared with women of other ethnic backgrounds, Moldovan women were the most likely to name traditional methods as reliable contraceptives. Conversely, the preference for the IUD was highest among Russian women (54%), who were also the least in favor of traditional methods (5%). As expected, among women currently using contraception, their opinions of most effective method were consistent with the methods they use. Among non-users, many of whom are young unmarried women, a high proportion favored condoms (23%), after the IUD (34%), whereas 13% were not able to express any opinion about the best contraceptive method. 7.2 Opinions on Safety of Birth Prevention Methods Widespread concerns about potential adverse health effects of contraceptive methods, especially the pill (see Chapter VI), can be an important deterrent to their use. To explore these 126 concerns, the survey asked all women to rank specific methods of birth control, including pregnancy termination, with regard to their potential risk of side effects. As shown in Table 7.2.1, the majority of women perceived induced abortion, either conventional or mini-abortion, as very risky for a woman's health. Induced abortion was associated with high probability of having health problems by 90% of respondents, as was mini-abortion (87%). Tubal ligation, the IUD, and the pill were rated unsafe (associated with high risk of health problems) by sixth to third of respondents. About one in ten women considered injectables to be unsafe, but two- thirds did not know about the method. Not surprisingly, very few respondents considered condoms to be unsafe (2%). Another important finding displayed in Table 7.2.1 is the apparent lack of opinion or knowledge about particular methods. As was the case with women's knowledge about method- specific contraceptive effectiveness (see Chapter VI), the relatively high proportion of women with no opinion about a method's safety indicates the extent to which they lack information about particular methods. The methods about which the highest proportion of women had no opinion were, as mentioned above, hormonal implants or injectable methods (66% of women did not know the risk level of Norplant and Depo-Provera), followed at a distance by tubal ligation and the pill (30%). 127 Opinions on health risks associated with specific methods of birth prevention are also shown in Figure 7.2. Beliefs of high risk for women's health associated with the use of induced abortion were almost unanimous followed by opinions of high risk associated with tubal ligation (33%). The IUD and the pill are thought of as a medium risk methods (45% and 36%, respectively) while condom was correctly identified as a low risk method by three-fourths of respondents. Characteristics of women who specified high health risks associated with birth prevention methods are shown in Table 7.2.2. Beliefs of high risk associated with abortion are universal, ranging from 86% to 96%. In fact, except for current users of contraception, there is little variation in responses for any method. Not surprising, current users were less likely to rank their own methods as having a high risk of side effects, compared with nonusers of the same method. For example, only 6% of pill users said their method has a high risk, compared with 17% of all women. 128 129 130 7.3 Opinions on the Best Source of Information About Contraception The majority of women (75%) would like to have more information about contraceptive methods (left panel in Table 7.3). The desire for more information is slightly higher in rural areas, including the mostly rural Central and Southern regions (79%). Young adults and never married women were much more likely to ask for more information about contraception (92- 93%). Desire for more information was not affected by women's education or socioeconomic status. Russian women were slightly less likely to say they want more information. Contraceptive status at the time of the interview had little influence on the desire for more information. Condom users, mostly young women, express a slightly higher desire (82%) than users of other methods (excepting tubal ligation) or non-users to receive more information on contraception. As shown in Figure 7.3 and the right panel of Table 7.3, most women who would like to know more about contraception think that a physician (64%) would be the most reliable 131 source of information. The second most reliable source of information was the mass media (25%) and the third, named by considerably fewer respondents (4%), was a nurse or a midwife. Less mentioned sources were: a relative, including the mother (3%), somebody who uses a contraceptive method (2%), or a friend, including the partner (1%). 132 CHAPTER VIII CURRENT AND PAST CONTRACEPTIVE USE In 1998 the Government of Moldova, with technical assistance from UNICEF, UNFPA, USAID, and WHO, formulated the year 2003 reproductive health objectives, which include: increasing the use of oral contraceptives to 15%; reducing induced abortion rates and abortion complications by 50%; lowering maternal and infant mortality, two pivotal measures of the health status and health services in a community, from the current levels of 48.3 maternal deaths per 100,000 live births to 20/100,000, and from 14.8 infant deaths per 1,000 births to 12/1,000 (MOH, 1998). To attain these objectives, the government plans to adopt new strategies, including reorganizing and optimizing family planning services at the regional level, introducing family life education in school, developing an IEC system with a focus on family planning and other reproductive health issues, and developing the legal framework that will enable each individual to have free and unrestricted access to reproductive health services. One of the greatest challenges for the newly implemented national family planning program is to help women successfully plan their births and reduce the risk of unintended pregnancies and subsequent abortions. In an era where advanced contraceptive technology enables couples to have considerable control over their fertility, family planing represents the foundation in attaining these national goals. 8.1 Current Contraceptive Prevalence As can be seen in Table 8.1.1 and Figure 8.1.1, contraceptive prevalence among women currently in legal or formal unions was very high (74%) with two-thirds using modern methods. About one in two women were using a modern method in the month preceding the interview, whereas only one in four were using a traditional method. With the exception of childless women, whose contraceptive prevalence was very low, modern method prevalence was between 40 and 62% and traditional method prevalence between 15 and 32%. For the entire country, the proportion of contraceptive users employing modern methods is 68%, ranging between 59 and 80%. The proportion of women currently in union using any contraceptive method was not significantly higher in urban areas compared with rural areas, was highest in Transnistria (78%), was positively correlated with age (from 64% among young adults to 76% among women over 34 years 133 134 135 of age), and increased directly with educational level, socio-economic level, and with the number of living children. Women of Russian and Ukrainian ethnic backgrounds have slightly higher contraceptive prevalence than other ethnic groups (not shown). Modern contraceptive use was lower in rural areas than in urban areas (44% vs. 56%), among young adults than among women aged 25- 34 or 35 and over (40% vs. 54 and 51% respectively), among women who did not complete secondary education (41%), those living in households with low socioeconomic level, and substantially lower among childless women (15%). Although, among all subgroups, the use of modern methods surpassed the use of traditional methods by a considerable margin, some women were more likely to use a traditional method (principally withdrawal) than others. The proportion of traditional method users was higher than the country average of 24% in rural areas (28%), in the Northern region (31%), among less educated women (27%), among those with low socioeconomic status (32%), and among women with three or more children (29%). As shown in Figure 8.1.2 and Table 8.1.2, the IUD was by far the most widely used method (38%) accounting for about half of contraceptive use and three-fourths of all modern method use. 136 137 The other modern methods are used far less often than the IUD. Condoms are used by only 6% of couples and represents about 12% of the modern method prevalence. Tubal ligation, despite an overwhelming desire to have no more children (see Chapter 4), is used by only 3% of women currently in union. Also, the use of oral contraceptives is consistently low (2%). The second most prevalent method of family planning is withdrawal, used by 22% of women currently in union. The calendar method is seldom used (2%). Although the overall proportion of women currently using a method varies slightly by background characteristics, the choice of a specific method sometimes differs by a considerable margin among different subgroups. The use of IUD is considerably higher than average in Transnistria (48%) and among women of Russian background (45%), whereas among women living in Chisinau or the Northern region of the country, women age 15-24, those with lower educational and socioeconomic status (not shown), and those unemployed, IUD use was lower than the national average. Condom use was more prevalent in urban areas than in rural areas (9% vs. 3%), among residents of Chisinau (11%) and Transnistria (9%), among young women (10%), was directly correlated with education and socioeconomic status, and was higher among Russian and Ukrainian women. The use of other modern methods did not vary significantly by background characteristics. 138 The withdrawal method was significantly higher among rural residents (27%), among residents of the Northern region of the country (30%), among women with lower levels of education (25-26%), and among women with low socioeconomic status (29%). Table 8.1.3 and Figure 8.1.3 show the use of specific methods among women currently in union according to the number of living children they have. The use of IUD is very limited among childless women (3%) and increases markedly with increasing number of children, to 36% among women with one child and 45% of women with two or more children. On the other hand, condom and oral contraceptive use are inversely correlated with the number of children. These two methods are only rarely chosen by women with three or more children. As expected, tubal ligation is mostly used by women with at least two children, but even among them its prevalence is quite low (5%). Withdrawal use increases steadily with number of living children whereas the calendar method does not show any significant association. 139 The IUD is by far the method of choice for all currently in union women with children, whereas childless women choose either withdrawal (8%) or the condom (8%). As shown in Table 8.1.4, women residing in municipalities have a slightly higher but not significantly higher contraceptive prevalence than women in other urban or rural areas; however, the higher ratio of modern methods to traditional methods in urban versus rural areas is significant (3:1 vs. 1.6:1). There is variation in contraceptive method use by residence, with lower use of condoms and higher use of withdrawal in rural areas, and higher use of condoms in urban areas, especially in the four municipalities. Use of pills is also highest in municipalities (4%), equaling the use of contraceptive sterilization. 140 Although the overall percentage of women currently using a method varied only slightly by ethnic background (Table 8.1.5), the choice of contraceptive methods used, specifically the choice between a modern or a traditional method, does vary. The ratio of modern to traditional methods is highest for Russian and Gagauzan women (6:1 and 3:1, respectively) and lowest for Moldovan, Ukrainian, and Bulgarian women (approximately 2:1), who have the highest prevalence of withdrawal. IUD use is higher among Russian and Gagauzan women, whereas condom use is more prevalent in Russians and Ukrainians. 141 This section focuses mostly on women in legal and consensual marriages because they represent 85% of sexually experienced women (the majority of which are currently sexually active), have greater frequency of intercourse, have higher fertility and more accidental pregnancies, and constitute the common denominator for other national and international studies of contraceptive prevalence. Many women previously married or never married who have ever had intercourse were not currently sexually active and therefore not in need of contraception (see Chapter IV). Not 142 surprisingly, the proportion of these women currently using contraception is much lower than among married women (Table 8.1.6), ranging from 27% among previously married to 7% among never married women. Also, contraceptive method used varies significantly by marital status. Overall, previously married women were more likely to use a modern than a traditional method. The ratio of modem to traditional methods was highest for previously married women (5.6:1), lower for never married women (2.5:1) and lowest for married women (2:1). The IUD is the most widely used method among both married and previously married women (38% and 16%, respectively) but is seldom used by never married-women (1%). 8.2 Source of Contraception In order to assess sources of contraceptive mefhods for women currently in union, the MRUS included questions about where current users of supplied contraceptive methods obtain their methods. Since the family planning program was only recently re-organized by the government and nongovernmental organizations, and since a nationwide contraceptive logistics system is still under development, information regarding sources of contraception is of great interest to program officials. As shown in Table 8.2, the public medical sector was the most important source of contraception (72%). Women's outpatient clinics supplied 41% of women currently in union with their current method of contraception. Additionally, maternity hospitals supplied 21% of women whereas circumscription clinics (in urban areas) and dispensaries (in rural areas) supplied 10% of women. Pharmacies are the second most important source for women, supplying 23% of current users. Because pharmacies are the subject of a rapid process of privatization, it is very difficult to differentiate between public, private and mixed ownership status. Other commercial sales outlets (stores or street markets) provided less than one percent of women. Other sources, such as partners, supplied 3% of users, whereas friends and relatives supplied 2% of users. Sources varied greatly according to the particular contraceptive method used. Women's outpatient clinics were the first source for IUD users (50%) and the second source for women using oral contraceptives. Maternity hospitals and pharmacies were the second source of lUDs, each supplying about 18% of IUD users (IUDs purchased in pharmacies are brought to a medical facility to be inserted). Pharmacies were the principal provider for condoms and pills, supplying 59% of women whose partners use condoms, and 52% of pill users. Not surprisingly, partners constituted the second source for condoms (22%). Virtually all contraceptive sterilization procedures took place in maternity hospitals. 143 8.3 Preference for Other Methods and Dissatisfaction with the Current Method To assess method acceptability, all current users of contraception were asked if they would prefer to be using some other method of preventing pregnancy. Overall, 80% of women were satisfied with their current method. However, as Table 8.3.1 shows, about one in five women currently using contraception said they would prefer another method (about half of them would prefer using an IUD) and percentages differ considerably depending on the method used. Male- controlled methods (condom and withdrawal) were most likely to not be among the preferred methods. About 42% of condom users and 41% of withdrawal users would prefer to use another method, mostly IUD. One in four women using periodic abstinence and one in five pill users 144 indicated a preference for another method. The great majority of IUD users, however, were satisfied with their method (only 7% would prefer to use another method). None of the small percentage of women who had been sterilized would have liked to use another method. As mentioned above, the IUD is the most preferred method (11%) among women who would like to use another method, especially among traditional method users. The next preferred method was the pill (4%), indicated as a choice mostly by condom users. Only 1 % of users would prefer to be contraceptively sterilized. Table 8.3.2 presents the most important reason for which women did not switch to the preferred method. Overall, about a third of those who would like to use another method were still thinking about this change (35%). One-fifth of respondents who wanted to use another method were concerned with potential side effects associated with the preferred method. A relatively high proportion (15%) considered that the cost associated with their preferred method is the most important barrier against switching. Lack of availability of the preferred method was mentioned by 13% of respondents. 145 The most important reason for not switching to the IUD, the method most likely to be preferred, was woman's indecision about the change (40%), followed by fear of side effects (19%) and the method cost (15%). For those preferring pills, fear of side effects was the most commonly mentioned reason (30%), followed by postponement of the decision to switch (26%), and difficult access to oral contraceptives (difficult to find and costly method). Lack of availability was overwhelmingly mentioned by women who would like to use injectables or Norplant (46%), whereas women who would consider a permanent method (tubal ligation) were still thinking about their decision (42%) or were concerned with the cost of the procedure (24%). The second most important barrier to switch to condom use, mostly among traditional method users, was the price, preceded only by the couple's indecision. 146 Overall, 13% of users expressed dissatisfaction with their current method. Conversely, 87% expressed satisfaction. Table 8.3.3 and Figure 8.3 shows the percentage of current users who expressed dissatisfaction with their specific methods. Complaints were more common among users of coital-dependent methods (condom and withdrawal) than among women using other methods. IUD users and the low percentage of women who have been contraceptively sterilized expressed the fewest complaints (7% and 3%, respectively). Side effects represent almost all complaints expressed by IUD users. Dissatisfaction with the pill was mostly related to the presence or fear of side effects and the difficulty in using the method (difficult to remember). Complaints about condoms consisted mostly of difficult use, unpleasant to use, partner dissatisfaction with the method, and method failure. Criticisms of withdrawal were concentrated on partner disapproval and method failure. 147 8.4 Users of Non-Supplied Methods Every respondent who was currently using any non-supplied method (calendar method and withdrawal) was asked whether a number of factors were "important" or "somewhat important" in their decision not to use a more effective method. These factors included: fear of health or side effects that may be associated with the use of modern methods; lack of knowledge about other methods; partner preference; cost or availability of other methods; religious beliefs, and medical recommendation against modern methods. As shown in Table 8.4.1, most women stated that fear of side effects (80%), lack of knowledge about modern methods (68%), partner preference (61%), and cost (56%) or availability (43%) of modern methods were the major factors influencing their decision not to use a modern method. One fourth (27%) cited a doctor's recommendation and few women (13%) considered their religious beliefs an important factor in their contraceptive decision. 148 149 Among users of non-supplied (traditional) methods there was practically no significant variation in the proportion mentioning that fear of health/side effects was important in their decision to not use a modern method, by background characteristics. Lack of knowledge was more often mentioned by women using withdrawal, women in rural areas, 15-24 year-olds, those with less than post-secondary education, and women with low SES. The cost and availability of modern methods was mentioned more often by withdrawal users, women living in rural areas, young adults, women with less than a post-secondary education, and ethnic Moldovans. Similarly, religious beliefs were more important for withdrawal users, rural women, women with low SES, and Moldovans. The "doctor's recommendation" was cited more often by withdrawal users. A substantial number of factors mentioned by women who chose to use traditional methods as important in their decision-making could in fact be influenced by adequate contraceptive counseling and improved access to family planning services. Table 8.4.2 presents the opinions of women using non-supplied traditional methods regarding the effectiveness of their current method relative to "modern methods like the IUD or the pill." It is notable that more than two-thirds consider their method more effective (25%) or equally effective (43%) compared with modern methods and only 28% recognized that the IUD or the pill are more effective methods in preventing pregnancy. Overall, less than 5% admitted that they did not know if their method is more or less effective. Calendar users were more likely to believe in high relative effectiveness (this category includes women who think their method is more effective or equally effective) of their method (81%). Perceived relative effectiveness was highly associated with the desire to use another method in the future. As expected, women who did not want to change their current traditional method were also more likely to think highly of its effectiveness (82%). Those who said their preference for a future method would be either the IUD or another supplied method were the least likely to believe that their current method is relatively effective (44%-45%). To increase the use of more effective methods, the national family planning program should concentrate on heightening public awareness of the relative effectiveness of various types of contraception, including contraceptive sterilization, disseminating information about the health effects of various methods, including their health benefits, and improving access to modern methods. 150 151 8.5 Recent Trends in Contraceptive Use The MRHS questionnaire included a detailed five-year contraceptive "calendar", where the contraceptive use, pregnancy events, and marital status were recorded monthly starting with January 1992 to the date of the interview. These data were used to compute 12-month contraceptive prevalence rates for the most recent years (Table 8.5 and Figure 8.5). There has been a steady and relatively strong rise in the overall contraceptive prevalence among all women and among women in formal or consensual unions. Between January 1992 and December 1996 contraceptive prevalence rose from 45% to 54% among all women and from 68% to 73% among women in union. Most of the increase was the result of higher usage of modern methods. Since 1992, contraceptive prevalence of modem methods has risen by 35% among all women (from 26% to 36%) and by 12% among women in union (from 43% to 48%). 152 153 Most of this increase was due to a net growth in IUD and condom use, especially among unmarried women. The IUD prevalence among all women increased by 29% (from 21% to 27%) and the condom use increased by 43%, from 3.5% to 5%. Female sterilization and oral contraceptive use, although very low in absolute percentages, were relatively greater, resulting in an approximate doubling of prevalence in 1996 compared to 1992. The growth in oral contraceptive use was most rapid in the most recent year, coinciding with a stagnation in IUD use. This raises the possibility that pill use may, to some extent, start substituting for IUD, especially after the IEC campaign promoting oral contraceptive use had been launched at the end of 1995. 154 8.6 Contraceptive Failure and Discontinuation Contraceptive failure (probability of becoming pregnant while using a contraceptive method) and discontinuation (probability of stopping use of a contraceptive method for any reason, including getting pregnant) rates were calculated using information collected through the detailed month-by- month pregnancy and contraceptive use history starting with January 1992. If, as is usually the case. some women did not report pregnancies ending in abortions and they had been using contraception at the time of conception, these rates may be underestimated. The overall level of abortions reported in the survey for the last three years was identical with that reported by official statistics (see also Chapter IV), but, if we go back in time, the average abortion rate reported in the survey for 1992- 1997 is actually 17% lower than that reported by official sources (data not shown). Thus, the rates reported here are minimum estimates, and the true rates are probably somewhat higher than shown in Table 8.6.1. Life table analysis of segments of contraceptive use was employed to estimate the monthly probabilities of failure and of discontinuing contraceptive use for all women using a contraceptive method during the observed period (January 1992-September 1997). Linking these probabilities, 12-, 24-, and 36-month contraceptive failure and discontinuation rates can be calculated. These rates represent the proportion of users who stop using their method within the first year, second year or third year of use for any reason (discontinuation rate) or because they become pregnant while using the method (failure rate). The one-, two-, and three-year intervals of use refer to uninterrupted 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 in which she had used another or no method. When more than one method had been used during any month, that month's contraceptive experience was assigned only to the more effective of the two methods. Overall, 13% of users became pregnant during the first year, 22% after two years, and 26% after three years. Failure rates varied considerably by the contraceptive method used. The IUD had the lowest failure rate at one, two, and three years. Between 1.9% and 4.4% of IUD users became pregnant while using this method. Although the one-year IUD failure rate was very low, it was twice as high as the most recent data published in the literature—0.8 failures per 100 women using the method (Hatcher RA et al., 1997). The failure rate for oral contraceptives was much higher but consistent with the published one-year failure rates for common use (6-8%). About 6% of pill users became pregnant in the first 12 months of use and the percentage of failures rose to 17% after two or three years of use. Condom users reported failure rates of 13% during the first year and 23% 155 156 and 30%, respectively, after two and three years. The apparent high failure rate reported for the condom is consistent with its reported contraceptive efficacy. The highest failure rates were reported by users of the calendar method and withdrawal; nearly one-fourth became pregnant in the first 12 months of use and about half became pregnant after two or three years. Although the overall and method-specific failure rates (excluding users of non-supplied methods) were within expected levels, the survey data showed considerably higher discontinuation rates. Overall, about a third of women discontinued their method at one year, half at two years, and almost 60% after three years of use. More than half of discontinuations were caused by reasons other than method failure (method failur
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