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 failures accounted for 13.3/32.6 x 100=40% of discontinuations). Of the five methods shown in Table 8.6.1, the IUD was the only one with a low discontinuation rate at one year (6%), but twice and three times as many IUD users stopped using the method at two and three years (12% and 20%, respectively). However, 80% of IUD users continued to use the method after three years. More than a half (56%) of pill users discontinued their method after the first year, despite its low failure rate. Less than one in five women continued to use the pill after three years. Condom discontinuation shows a similar pattern. Only one in two women used the condom for more than one year and only one in five used it for more than three years. Interestingly, for all these methods, method failure played a minor role in the women's decisions to stop using the method after one year, accounting for only a third (for IUD) to a ninth (for pills) of the discontinuation reasons. Conversely, for withdrawal and the calendar method, also associated with very high discontinuation rates at one (42%-44%), two (66%-73%), and three years (77%-85%), method failure was the main reason for discontinuation. In addition to method failure, women using contraception stop their method for many other method-specific reasons. Table 8.6.2 presents some reason-specific discontinuation rates at one year for the five most commonly used methods. The IUD discontinuation rate in the first year of use, the lowest among all contraceptive methods, is heavily influenced by side effects associated with method use. More than a half of IUD users discontinued for this reason, while one-third of them got pregnant using the method. The experience of side effects was also the principal reason for discontinuing pill use. More than one-third of women who stopped using the pill (21% of 56%=38%) did so because of side effects; 23% stopped the pill because they desired to get pregnant (13% of 56%=23%); 20% switched to another method; and 20% said that their doctor recommended that they stop using the pill. Almost one-half of women whose partners were using condoms discontinued use for partner-related reasons (either because the partner did not want to use the method anymore or because they separated from their partner). Method failure, desire to start 157 another contraceptive method, and desire to get pregnant, accounted for most of the other reasons. Method failure was the most important reason in discontinuation of withdrawal or the calendar method. Partner-related reasons, desire to resume childbearing, and switching to other methods were other important reasons to discontinue these methods. 8.7 Discussions About Contraception with Current Partner As shown in Table 8.7, only slightly more than half (56%) of women who had a partner discussed contraception with their partner during the 12 months preceding the interview. The youngest women were the most likely to have talked about contraception with their partners (69%) whereas women aged 35 years or older were the least likely (46%). Reports of contraceptive discussions increased directly with education and socioeconomic level, and were inversely correlated with the number of living children (data not shown). Although a causal relationship 158 159 between eontraceptive discussions and contraceptive use cannot be drawn, it is important to note that only 39% of non-users reported conversation with their partners about contraceptive methods, whereas current users of contraception (excepting women with tubal ligation) were much more likely to have had such discussions; between 62% and 89% of users reported discussions about contraception but it is unclear if these discussions were before or after they started using their current method. However, virtually all women who reported such conversations (data not shown) said that their partners are in favor of using birth control methods. 8.8 Reasons for Not Using Contraception As shown in Table 8.8, among women currently in union, the most common reason for not using a contraceptive method was pregnancy related (32% said they want to get pregnant and 22% were currently pregnant or nursing). An important proportion of women in union (19%) were not currently using a method, either because they tried to get pregnant in the past two years and did not 160 succeed (subfecund) or because they had gynecologic surgery or other medical problems which prevented them from getting pregnant. Very few women (1%) reported partner infecundity/ subfecundity as a reason for not using contraception. About one in six women reported lack of current sexual activity as the most important reason for not using a method. Noteworthy, very few women reported program-related reasons as contributing to their decision not to use a method: lack of knowledge about contraception (3%), access reasons (3%), personal or partner opposition to contraceptive methods (2%), and fear of side effects (1%). Reasons for not using a method differed sharply by current age. Younger women in union were more likely to either seek to become pregnant or already be pregnant or in the postpartum period, whereas women aged 35-44 years were more likely to not be sexually active (44%) or not be able to get pregnant (41%). 8.9 Potential Demand and Unmet Need for Contraception Another approach to assess the potential demand for family planning services, other than the analysis of contraceptive behaviors among women in union, is to define the contraceptive needs of women in relation to their fecundity and stated reproductive preferences, regardless of their marital status. The total potential demand for contraception is generally defined as a sum of current contraceptive use (met need) and the additional contraceptive use that would be required to eliminate the risk of unwanted or mistimed births. The last component, termed "the unmet need" for contraception, has proved to be a worldwide indicator in planning program strategies, allocating resources and analyzing FP program outcomes (Bongaarts J., 1991). Estimates of the total demand and unmet need for contraception may vary from one survey to another if the criteria used in defining the terms are not consistent or survey questions are not the same. The conventional approach used to calculate unmet need is to exclude women not currently in union, women currently using any contraceptive method, those not currently exposed to the risk of pregnancy (women not sexually active, currently pregnant women, women in postpartum abstinence or amenorrhea), infecund or subfecund women and women who currently want to become pregnant (Bongaarts J., 1991). By restricting the denominator to women in union, the percentage of women with an unmet need of family planning services is likely to be higher, since married women generally have a higher risk of unintended pregnancy and a higher potential demand for family planning methods. However, by using this definition, the absolute number of women estimated to be in need of contraception does not include unmarried women and women with special needs (e.g. adolescents). As can be seen in Table 8.9.1, the survey found that, although the 161 majority of women who should use a FP method are married or in consensual unions (79%), a significant proportion of formerly married (39%) and 13% of never-married women also have potential demand for family planning services. According to the most recent census data, these proportions translate into an estimate of almost 590,000 women aged 15-44 years in need of family planning services with 230,000 of them at risk of an unintended pregnancy because they do not use 162 any method or use traditional methods. These figures include almost 530,000 women currently in union, of whom almost 200,000 are at risk of an unintended pregnancy. Although the majority of women in need of family planning, regardless of marital status, were currently using a contraceptive method and only 6%-12% had an unmet need for contraception, these figures are inconsistent with the relatively high level of unintended pregnancies and 163 subsequent abortions shown in Chapter IV. In countries with high use of traditional methods, the standard definition of unmet need masks the real need for more effective contraception. A better approach might be to estimate the unmet need for any or more effective contraception, which in the case of Moldova ranges from 29% among women in union to 16% among previously married women, and 8% among never married women (see also Figure 8.9). Patterns of contraceptive use by age also are strongly influenced by reproductive behaviors and goals. Table 8.9.2 shows that the potential demand for contraception increases steadily with age, from 34% among young adults to 76% and 74%, respectively, among women aged 25-34 and 35-44 years. Although the unmet need estimated by the classic definition is not influenced by age, the need for any or more effective contraception increases markedly with age, from 16% among women age 15-24, to 26% among women 25-34 years of age, and 29% among those aged 35-44. 164 8.10 Contraceptive Sterilization Despite the fact that the vast majority of women with two or more children want to stop childbearing, contraceptive sterilization (neither tubal ligation nor vasectomy) is seldom used in Moldova. The MRHS found that only 5% of women with two or more children had been sterilized (see Figure 8.1.3 on page 138) and that there were virtually no vasectomies being done. Throughout Eastern Europe permanent methods of contraception are not currently promoted, mostly because the continuing concern about a negative rate of population growth. Recent surveys in the Czech 165 Republic, Romania, and Russia also revealed low prevalence of sterilization. In many of these countries legal provisions to support voluntary sterilization are very restrictive and modern techniques of tubal occlusion are not generally available. In Moldova, tubal ligation was legalized in 1994 (Order no. 152 of August 1994, MOH) and currently is available to women with at least 3 children, women aged 40 years or older, women aged 30 years or more who have at least 2 children, or women who have a problem that makes childbearing dangerous to their health or survival. Regardless of the regulations on when sterilizations are permitted, the survey results show few women to be interested in being sterilized. Overall, among fecund respondents who want to have no more children, only 10% claimed to be interested in sterilization (Table 8.10). The most commonly stated reason (Figure 8.10) for not being interested in sterilization was the fear of operation or side effects post-surgery (35%), age too young or too old (17%), that women simply "had not thought about it" (15%), or being ambivalent about their decision to have no more children. Other reasons included lack of information about sterilization (6%), the cost of the procedure (4%), not having a current partner (4%), religious or cultural constraints (3%), and preference for other contraceptive methods, especially the IUD (3%). 166 CHAPTER IX CONTRACEPTIVE COUNSELING An important component of the newly developed reproductive health strategy is to develop family planning programs and train health professionals to provide family planning counseling. The MRHS included a series of questions designed to capture the interactions between family planning providers and their clients: specifically, the survey asked about the extent to which health professionals provided basic information and services to women who have used a modern contraceptive method or had an abortion or a birth during the previous five years. 9.1 Communication with Family Planning Providers Women who have used at least one modern contraceptive method in the previous five years were asked who advised them to use their last modern method. If the advice came from a health care provider, either physician, nurse, or midwife, they were asked if they received any information about other methods, how effective their method is, and what side effects may be associated with its use. As shown in Table 9.1, three out of four women were advised by a heath care provider to use their current or last modern method (68% by a physician and 8% by a nurse or midwife). One in ten women started using their last method at the suggestion of their partners, primarily condoms. Only in 6% of cases was the choice of the method made by the woman herself. In the remaining cases, the choice had been suggested by a friend (3%), a relative (3%), or somebody else (1%). The source of advice varied widely by last method used. Almost all IUD users and women with tubal ligation had chosen their method at the advice of a heath care provider (91% and 99%, respectively), but only 13% of condom users were advised by a physician or a nurse/midwife. Most women who had used condoms did so because their partners suggested it. Almost three out of four women were advised by a health care provider to use the pill. It is important to know what type of advice these women received from health care providers, as the providers' interactions with their clients and the messages conveyed during these interactions can affect client satisfaction with services and continued utilization of services in the future, as well as correct method use. 167 As shown in the bottom panel of Table 9.1 and Figure 9.1, during provider-client interaction only one in two women received general information about other contraceptive methods and information about the effectiveness of the method they were using, compared to other methods. However, about three-fourths of women reported that the provider had explained the possible side effects of the method chosen. Women using tubal ligation were less likely to receive information about other methods, contraceptive effectiveness, or possible side effects. Pill users were more likely to make an informed choice, since 79% had also received information about other methods, 74% were told about the pill's effectiveness, and 79% received information about possible side effects. 168 9.2 Satisfaction with Counseling Services Women who have used a modern method in the past five years were asked about their satisfaction with the service provider (Table 9.2). Only one-fifth (22%) of modern method users were very satisfied and another 66% were satisfied. One in twelve women was somewhat satisfied (7%) and 5% were dissatisfied. Russian women and women in the Transnistrian region were much more likely to be very satisfied (47% and 49%, respectively). Women who were counseled about other birth control methods at the time of making their contraceptive decision were more likely to be very satisfied than those who did not receive comprehensive counseling (30% vs. 12%). Similarly, counseling about method-specific effectiveness and side effects was associated with higher satisfaction with counseling. 169 170 9.3 Post-abortion and Postnatal Counseling Under the current law, (Order No. 152, of August 1994, Moldovan Ministry of Health) women who have had an abortion should receive contraception counseling. In addition, there are specific recommendations to help women who have had abortions performed for medical or social reasons. They can get an IUD inserted or can have laparoscopic female sterilization performed after abortion without charge. All women who have had an abortion since January 1992 were asked if they received post-abortion counseling after their most recent abortion procedure, and if they received any contraceptive method or prescription for a method following the procedure. Table 9.3 shows that only 60% of women who had an induced abortion since the beginning of 1992 said that a health professional had spoken with them about ways of preventing pregnancy. The percentage who received a contraceptive method or a prescription for contraceptives was considerably lower (25% and 14%, respectively). There was not much variation in the prevalence of post-abortion contraceptive counseling by women's background characteristics. Young adults were slightly more likely to have received advice about contraceptive methods (65%) than older women (58-59%). Contraceptive advice increased directly with women's socioeconomic level and with the number of previous abortions; women with three abortions were more likely to have spoken with a health professional about contraception after the abortion procedure than women reporting one abortion (69% vs. 56%). Post- abortion counseling increased slightly after the new abortion legislation was enacted in 1994. Women whose last abortion was performed in 1996-97 or 1994-1995 were slightly more likely than those with earlier abortions to have been told by a health provider about methods of preventing pregnancy (62-63% vs. 55%). Receiving a contraceptive method after abortion was more commonly reported by women living in urban areas than in rural areas (27% vs. 21%), probably because of unequal distribution of hospital supplies by geographical areas, especially IUDs. Women from the Southern region (30%), young adults (29%), and women with middle or high socioeconomic status (26-29%) were more likely to receive a contraceptive method post-abortion. Distribution of contraceptives post- abortion increased slightly among women with two or more abortions (26% and 28%, respectively), compared to women with only one abortion (22%). Prescriptions for a contraceptive method were received more often by women in the Northern region and Transnistria. As shown in Chapter V (Table 5.3), among women who have had a birth since January 1992, only 58% received any information about family planning during postnatal care. 171 172 CHAPTER X REPRODUCTIVE HEALTH ATTITUDES Moldova's reproductive and birth control patterns have shared similar features with Russia and other countries of the former Soviet Union. Fertility decreased sharply, to below replacement levels, while induced abortion has been the main method of fertility control and modern contraceptives have been underutilized. The relatively isolation of the U.S.S.R. from the contraceptive advancements in Western countries affected both the knowledge about and the availability of high-quality contraceptive methods. Compounded by ignorance and fatalistic attitudes toward health issues, and the availability of and high tolerance for pregnancy termination, there was high reliance on induced abortion as the principal means of birth prevention (Remennick L, 1991, Popov A, 1996). These patterns were further shaped by a climate of strong moralistic principles, which condemned premarital and extramarital pregnancies, disapproved of sex education in school, discouraged open discussions about sex- related issues, and accounted for strong prejudiced attitudes toward sexuality. In addition to exploring attitudes about family size and induced abortion, the 1997 MRHS also included questions related to the attitudes that surround reproductive decision- making, pregnancy resolution, and gender roles in Moldova. The results of questions on these topics should prove useful for developing and modifying elements of reproductive health education programs and curricula. 10.1 Ideal Family Size Respondents were asked what they thought was the ideal number of children for a young family in Moldova. This question is meant to explore general attitudes of reproductive-age women and not their personal decisions about ideal family size. However, some respondents may have been influenced by their personal experience (actual number of children). Table 10.1 presents the mean ideal number of children by selected background characteristics. The mean ideal number of children is 2.2 and varies from 1.9 to 2.6. The mean ideal number of children was higher for women in rural areas than in urban areas (2.4 vs. 2.1) and for residents of the mostly rural Central and South regions (2.4-2.5), while residents of Transnistria reported the lowest ideal family size (1.9 children). 173 174 The ideal number of children was 2.1 for young adults, compared with 2.3 for older women. Higher means were reported by women with low education (not shown) and low socioeconomic status (2.4 children). The ideal mean number of children was directly correlated with the actual number of children; women with three or more children reported the highest ideal mean number (2.6 children). Women of Russian (mostly residents of Transnistria) and Ukrainian ethnic background reported lower mean ideal numbers (1.9 and 2 children, respectively), compared with women of Moldovan or other ethnicity (2.3 children). Religious women with frequent church attendance (at least once a month) reported a higher ideal mean than women who never attend church (2.5 vs. 2.0 children). 10.2 Attitudes Toward Abortion Moldova, like all former Soviet Union republics, has a long history of reliance on abortion, which, in combination with traditional methods of contraception, was responsible for the rapid decline in fertility in the 1950s. Legally induced abortion on request was the main method of fertility control in Russia after the Socialist revolution. Even after 1936, when Stalin restricted abortion to narrow medical indications, clandestine abortions, provided by either medical providers or traditional practitioners, were widely used to avert unwanted births. In November 1955, abortion performed in the first trimester again became available "on request" when the restrictive legislation was repealed, largely to prevent illegal abortions and their associated complications. The Soviet Union became the country with the highest abortion rate in Europe; the number of pregnancy terminations exceeded the number of births by a factor of two or more. However, abortion rates varied widely among the Soviet republics and ethnic groups. The Russian Federation, Ukraine, Moldova, Kazakstan, Latvia and Estonia consistently reported record-high abortion rates between 1970 and 1988 (Remmenick L, 1991). In the mid-1980s, the induced abortion rate in Moldova (more than 90 abortions per 1000 women aged 15-49 were reported by the Moldovan Ministry of Health between 1985 and 1988) was superseded only by the abortion rate in the Russian Federation. In spite of an abrupt decline in recent years (from 115 abortions per 1,000 women aged 15-49 in 1987 to 43/1,000 in 1996), abortion rates in Moldova remain very high compared with those in Western Europe (Moldova MH, 1997). This long tradition of relying on abortion to control fertility, combined with economic difficulties that pressure couples to limit or delay childbearing, the lack of widespread availability of modern contraception, and relatively high use of traditional, less effective methods, is largely responsible for the continued high rates of abortion and its high acceptability in Moldova. However, personal values and reproductive norms could strongly influence abortion and contraceptive behaviors. The respondent's positions on abortion were explored by 175 asking whether "a woman should always have the right to make personal decisions about her pregnancy, including obtaining an abortion" and, for those who disagree that induced abortion should be an option for pregnancy resolution under any circumstance, whether an abortion should be permitted only under six specified circumstances: if "the woman's life is endangered by the pregnancy," if "the fetus has malformations," if "the pregnancy occurred as a result of rape," if "the woman's health is affected by the pregnancy," if "the woman is not married," and if "the couple has a low income and cannot afford the child." Overall, the proportion of respondents agreeing that a woman should always have the right to decide about her pregnancy, including resorting to abortion, was 81% (Figure 10.2.1 and Table 10.2.1). Only 1% of women opposed pregnancy termination under any circumstance, whereas 18% agreed with the acceptability of abortion being used only for certain reasons. Attitudes toward the right to decide about pregnancy resolution varied by respondents' sociodemographic characteristics, their religion and frequency of church attendance (religiousness), and previous abortion experience (Table 10.2.1). 176 177 Rural residents were slightly less approving of abortion always being an alternative for pregnancy resolution and more likely to never accept abortion. Residents of the North region and women in Transnistria were the most permissive about abortion being used in any circumstances. Education and socioeconomic status (data not shown) were inversely related with disapproval of abortion; the higher the level of educational attainment and SES, the lower was the likelihood to entirely oppose abortion. Respondents associated with religions other than the Orthodox church—Catholics, Protestants, and Jehovah's Witnesses—were less approving of abortion under any circumstance (not shown) and more likely to believe that abortion is never acceptable (10%). When religiousness was measured by frequency of church attendance, women who attended church services at least once a month were more opposed to abortion (4%) than those with less frequent attendance and less likely to approve abortion for any reason (72%). 178 Approval of abortion under any circumstance was inversely correlated with the ideal family size; the higher the number of children believed as ideal, the lower the acceptance of abortion, with 3% of women who believed that young families should have at least three children saying that abortion is never acceptable. The very few respondents who believed that a young family in Moldova should have as many children as "God gives" were the most likely to say that abortion is never acceptable (18%). Not surprisingly, acceptability of abortion was influenced by previous abortion experience. Women who had ever had an abortion were slightly more likely to agree that abortion in always acceptable. Figure 10.2.2 and Table 10.2.2 show the level of approval for abortion under certain circumstances among those who said that abortion is not always acceptable. Overall, respondents demonstrated three levels of acceptance under given circumstances that might motivate a pregnant woman to consider abortion: a higher level of abortion acceptability when physical or mental health complications are related to the continuation of pregnancy (physical deformities of the fetus and life-threatening health problems of the mother were considered acceptable reasons by 88% and 71%, respectively); a middle level of acceptability in cases of pregnancy resulted from rape (43%), the mother's health is endangered by pregnancy (38%), and low family income (32%); a low level of acceptability for out-of-wedlock pregnancy (16%). 179 180 181 Table 10.2.3 shows differentials in acceptance of each specific abortion circumstance by background characteristics. Generally, women in rural areas, residents in the North region, those with low or middle SES (not shown), those who are highly religious (monthly church attendance), or those who have never had an abortion were slightly less likely to approve of abortion for health reasons. Women residing in rural areas or in the South region, young adults, Moldovan women, women who had never had an abortion, and those who attend church at least once a month were slightly less likely to agree that financial problems could constitute a reason for abortion. Residents of the South region, women aged 25 or older, women with low education level, those with two or more children, and those who attend church at least once a month were the least likely to accept abortion if the woman is unmarried. All respondents, regardless of their opinion about "a woman's right to decide about her pregnancy, including obtaining an abortion," were asked if a woman who has an unintended pregnancy should keep the baby, give the baby up for adoption, or have an abortion (Table 10.2.4). Interestingly, fewer women agreed that unintended pregnancies should always be ended through induced abortion (61%), whereas a third thought that a woman who experienced an unintended pregnancy should give birth and keep the baby. Few women (4%) agreed with a third alternative, that of giving the baby up for adoption. However puzzling, these answers do not contradict each other; respondents's perceptions that a woman should always have the right to decide about her pregnancy, including having an abortion, reflect merely the strong desire for personal control over fertility and abortion and may be viewed as a necessary right that ought to be available on women's request in the absence of unlimited access to modern birth control methods. The opinions about terminating an unintended pregnancy by means of abortion elicit more ambivalence, probably reflecting the inherent moral difficulty in deciding between carrying the pregnancy to term or ending it in abortion. Urban residents, those living in Transnistria, women aged 25 years or older, ever married women, those with high education levels or high SES, women of Russian and Ukrainian descent, less religious women, and those with prior abortion experience were more likely to consider abortion as the best alternative if the pregnancy was unintended. 10.3 Attitudes and Perceptions About Reproductive Norms and Gender Roles Adherence to traditional reproductive norms and gender roles for women and men can play a major role in couples' reproductive and contraceptive decisions. Table 10.3.1 shows the proportion of women who hold conservative views toward four reproductive norms. Overall, three of four women believe "all people should marry," suggesting that less conservative type of 182 183 184 unions would not be acceptable. This opinion was less prevalent for urban than for rural residents (67% vs. 82%) and among women residing in Chisinau (62%). Endorsement of marriage was directly correlated with age and number of living children, and inversely correlated with education level and SES (not shown). Never-married women were slightly less likely to support this statement than ever-married women (70% vs. 75%). Among various ethnic groups, Russian women were the least likely to believe that all people should marry (65%). Those who attend church at least one a month were much more likely to think that people should marry than were non-religious women (82% vs. 65%). Table 10.3.1 also shows that two-thirds of reproductive-age women hold conservative views about sexual experience prior to marriage. Premarital chastity was perceived as important among rural women (79%), women living in the Central and North regions (76%), those aged 35-44 (75%), women with three or more children (85%), and highly religious women (80%). Women living in Chisinau, better educated women, women with high SES (not shown), and those of Russian and Ukrainian ethnic backgrounds were less likely to value postponement of sexual experience until after marriage. An important proportion of women have a fatalistic attitude toward fertility. Almost one in three respondents (29%) agreed that "women should have as many children as God gives them." This traditional attitude is more prevalent among rural residents than urban residents (37% vs 21%) and among women living in the Central region (40%); residents of Transnistria were the least likely to hold this perception (8%). Young adults and never-married women were slightly more likely to believe that the number of children in a family should be dependent on God's will. Lower educated women, those with low SES (not shown), and women who attend church monthly were much more likely to state that the number of children depends on "God." Only 7% of women believed that "child care is a woman's job," suggesting perhaps a desire of sharing child-care responsibilities in a society where the majority of women work outside the home. The groups with lower acceptance of child-care sharing duties were rural women, residents of the South and North region, women with three or more children, those with low SES or low education, and women who attend church monthly. However, this opinion did not register more than 13% in any subgroup. Communication between partners on family planning issues has been found to be a powerful predictor of increased contraceptive use and effectiveness (Becker S., 1996; Mott FL and Mott S., 1985). Thus, it was also important to explore Moldovan women's opinions and attitudes toward such communication. Although about one in ten women did not know how to answer the statements regarding communication about contraception, the majority of those who expressed an opinion disagreed that men and women "are not interested in talking to their 185 partner/spouse about contraception" (see Table 10.3.2). Overall, three-fourths of women did not agree that women are not interested in such conversations with their partners and 58% did not believe that men would not be interested in talking about family planning. Disagreement with these statements was slightly higher among urban women, women aged 25 or over, ever-married women, those with at least one child, those with a high SES, and Russian women. Contrary to the belief that most young people are influenced to have sex because their friends have sex, the survey showed that slightly less than half of women agreed with this statement. Disagreement with this statement was slightly higher among residents of the South region, young adults, never married, childless women, and those with a high SES. Along with views about gender roles in communication about family planning issues, the 1997 MRHS also explored attitudes about procreative responsibilities, measured in terms of men's and women's responsibility toward family size (not shown). Almost all women (92%) agreed that both partners should be responsible for deciding how may children the couple would have. Although the opinion of shared decision-making was universal, women with three or more children and those with low education or low SES were less likely to agree that the number of children in a family should be a joint decision. 186 CHAPTER XI SEX EDUCATION Over recent decades, concerns about teenage sexuality, pregnancy and sexual health have been mounting worldwide. Due to socio-economic and cultural changes, young people, especially adolescents, are sexually active at earlier ages than they have been in the past. They are more likely to have experienced premarital sexual intercourse, have a greater number of sexual partners and a higher incidence of unintended pregnancy and sexually transmitted diseases (STDs). Addressing unintended pregnancy and sexuality is a complex task. Prevention programs designed to reduce the rate of adolescent pregnancy and STDs require a multifaceted approach. School-based sex education is one important component of a broader effort. A number of studies have demonstrated that quality sex education programs can delay the onset of sexual activity and increase the use of contraception (Kirby D. et al., 1994; Dawson DA, 1986). In many countries sex education in school is mandatory. It is often taught from first to 12th grade as a component of the health and physical education curriculum, and aims to increase knowledge about human sexuality, sexually transmitted diseases, AIDS prevention, contraception and abstinence. Currently in Moldova, sex education is not included in the school curriculum. Under the previous government, elements of reproductive biology were taught in high school in the biology and human anatomy classes. In the past few years, several high schools have invited visiting health professionals to give short lectures about reproductive health, family planning, and sexually transmitted diseases (Moshin V. et al., 1996). These lectures have to be approved by the local school boards and their content varies from one school to another. Thus, sex education in some areas is sporadic or nonexistent and the quality and amount of information is variable. The Moldovan Ministry of Education became recently aware of the necessity of introducing quality sex education curricula in schools. Teens may acquire sexual information and sometimes misinformation from a variety of sources, including family, peers, media, and recently, after the censorship on information enforced during the "cultural revolution" had been lifted, from all types of movies and literature. A well-designed sex education curriculum should be developed and implemented throughout the Moldovan school system. It should cover, in addition to reproductive physiology and biology, information on STDs (including AIDS), methods of contraception, and the psychological and social considerations of sex roles and sexual relationships. Only then would myths and misconceptions be corrected, enhancing the likelihood that intimate relationships will be based on caring, affection and awareness of the other person's feelings. One of the objectives of the MRHS was to examine whether reproductive-age women in Moldova favor sex education in schools and to explore their opinions about the best age to start sex education. In addition, the survey was 187 188 designed to explore young women's exposure to sex education in school and discussions about sex education topics at home. Data about exposure to sex education and knowledge of young adults would be useful for the design of school curricula and training of teachers. 11.1 Opinions about Sex Education In School Table 11.1.1 shows that Moldovan women overwhelmingly support sex education in school, regardless of age, residence, marital status, parity, education, socio-economic status, or ethnicity. When respondents were asked their opinions about selected topics of sex education virtually all (98%) felt that reproductive biology, birth control methods, and STD topics should be part of the school curriculum. Among the 2% of respondents who did not agree with any sex education in school, more than three-fourths thought that sex education should be taught only at home and that sex education "may give adolescents the idea to begin sexual activity earlier." Among different subgroups, respondents' opposition to sex education in school never exceeded 3%. Women who agreed on the need for school-based sex education were also asked their opinion about the best grade level to start each topic of sex education (Figure 11.1). As shown in Figure 11.1 and Table 11.1.2, five in six women (84%) wanted sex education classes about "how pregnancies occur" before high school (before age 15), including 42% of respondents who supported these courses in sixth grade or earlier (age 12 and under) and 10% who believed they should be taught in elementary school (age 10 and under). Of those who believed that this topic should be introduced before high school, the majority favored age 11 or 12 as the right time to start lectures. Residents of urban areas, those living in Chisinau or in Transnistria, those who have one living child, those with post secondary education, and those of Russian descent were slightly more likely than others to say that sex education should be taught before high school and in elementary school. Opinions of reproductive-age women on the best time to start sex education courses about methods of contraception and STDs are shown in Figure 11.1 and Table 11.1.3. Among respondents who supported school-based education on these topics, there was again a strong preference to start the courses prior to high-school (81%), including 38% who would like to see these courses introduced before age 13 and 8% in elementary school. Similarly, respondents who favored the early onset of school-based courses about STDs and contraception were more likely to be urban residents, to live in Chisinau or Transnistria, to have one child, to be better educated (post-secondary education), and to be ethnie Russians. 189 190 191 11.2 Discussions About Sex Education Topics with Parents In order to examine the impact of sex education on reproductive health knowledge and sexual and contraceptive behaviors, we explored young women's exposure to sex education separately at home and in school. All 15-24 year-olds were asked if, before they reached age 18, they had ever talked to a parent about the menstrual cycle, how pregnancy occurs, birth control methods, or HIV/AIDS and other STDs. Table 11.2.1 and Figure 11.2 show the percentage of young women who had discussed selected sex education topics with a parent by selected characteristics. Overall, 79% of young women had talked about at least one sex education topic with their parents. Young women living in urban areas or in Chisinau, teenagers (15-17 and 18-19 years old), those who never had sexual intercourse, those whose mothers were better educated (technical college or more), those with higher socioeconomic status, and those of Ukrainian descent were slightly more likely to have had any 192 193 parent-child conversations. However, these discussions consisted mostly of talking about the menstrual cycle; conversations about how pregnancies occur, STDs and contraception were substantially less prevalent. Less than half of young women talked to a parent about human reproduction and only 29% and 27%, respectively, had discussed HIV/AIDS or other STDs. Talking to parents about methods of birth control was even less common (24%). Generally, parent-child conversations on any topic are more prevalent among urban than among rural residents. Topics like AIDS, STDs, and contraception were, on average, 50% more likely to be discussed in urban areas than in rural areas. By region, young women residing in Chisinau and Transnistria were much more likely to talk with a parent about STDs and contraception than women living in other regions. Transnistria's women were twice as likely to report such conversations as women in North, Central or the Southern region, and 50% more likely than women in Chisinau. 194 A slightly higher proportion of teens (15-17 and 18-19 years of age) than 20-24 year olds reported having discussed about menstrual cycle, AIDS, and other STDs with one of their parents. For example, talking to parents about AIDS and other STDs was 27% and 31 % and 23% and 31 %, respectively, among the younger cohorts compared to the oldest cohort. The increasing concern about the threat of AIDS epidemics in recent years is the most likely explanation for the higher prevalence of this topic in parent-child conversations in the younger age groups. However, we should not lose sight of the fact that only one-fourth to one-half of youth are having these discussions. Meanwhile, conversations about contraception did not differ by age group or sexual experience. Conversations about HIV/AIDS and other STDs were also more prevalent among women who have never had sexual intercourse than among those with sexual experience (32% vs 26% and 32% vs 23%, respectively). Discussions on all topics were positively correlated with maternal level of education. The largest difference in such conversations appears with respect to the topic of STDs and methods of birth control. Among young women whose mothers did not complete secondary education, only one in five and one in six, respectively, discussed these topics with their parents, compared with almost half of young women whose mothers had post-secondary education. Similarly, conversations on all topics were directly correlated with the socio-economic status, with the most substantial difference in talks about STDs. Ethnic Russians and Ukrainian young women reported more often that they talked to their parents about human reproduction, STDs, HIV/AIDS, and contraception. Parental conversations on sex education topics cannot be interpreted without taking into account the exposure to sex education in schools. As shown in Table 11.2.2, women who have had sex education classes also were more likely to have talked to a parent about the same topics, suggesting that when young women receive school-based sex education, either they or their parents may be stimulated to initiate conversations about sexual topics. Respondents who reported classes on HIV/AIDS prevention, other STDs, and methods of birth control were approximately twice as likely to report parent-child conversations about these topics compared with those who did not have classes. The association between formal and parental sex education on HIV/AIDS and other STDs is slightly stronger for 15-19 year-olds than for 20-24 year-olds, suggesting that while these topics gained popularity in school-based education, they, in turn, may have positively influenced parent- child conversations. However, the results may also indicate differences in recall. Respondents who did not have classes may not remember talking with parents about these issues, whereas those who remember having formal instruction may also better recall that they had home conversations about sex. Also, recall differences may explain in part why 20-24 years olds, who benefited less from formal instruction on HIV/AIDS and other STDs, were also less likely to report parental conversations on these topics. However, the change over time in reports of STDs, AIDS or contraception topics in both parental discussions and school-based sex education is consistent with the recent developments after 1990 when media began to discuss these health issues more openly and health professionals started to teach sex-education topics in schools. 195 11.3 Sex Education Instruction in School Young women were also asked whether, before they reached age 18, they had ever received formal instruction in school about the topics listed in Table 11.3.1. Those who reported exposure to formal instruction were asked the grade at which they first took courses on each specific topic. Table 11.3.1 and Figure 11.3.1 show the percentage of respondents who reported formal sex education on specific topics. Overall, most young women had at least one school-based course or class on sex education. Virtually all (94%) reported exposure to school-based sex education on at least one of the seven topics listed (data not shown). However, they were more likely to have received lectures on female and male reproductive biology, the menstrual cycle, and how pregnancy occurs (90%, 88%, 89%, and 69%, respectively) than lectures on HIV/AIDS, other STDs, and contraceptive methods (54%, 50%, and 34%). 196 197 Table 11.3.1 demonstrates no significant differences in exposure to sex education topics in school between urban and rural residents. Residents of Transnistria, however, were far less likely to have received lectures about HIV/AIDS, other STDs, or methods of birth control. Compared with respondents aged 20-24, adolescents reported higher levels of formal instruction on HIV/AIDS, other STDs, and contraception. For example, classes about HIV/AIDS were reported by 68% of 15-17 year-olds, 58% of 18-19 year-olds, and only 42% of 20-24 year-old women. Similarly, more teens reported courses on other STDs (60% and 53%, respectively, vs 40%) and on contraception (39% vs. 27%). These findings demonstrate that formal instruction in these topics has increased recently. More exposure to HIV/AIDS and other STDs in school was reported by Moldovans and other ethnic groups. 198 The study of age patterns for formal instruction demonstrates that, regardless of the topic, most courses are started at or before age 16 ( Figure 11.3.2). Among young women who received school-based sex education before age 18, the age at which instruction was first provided ranged from 11 (age 10 for HIV/AIDS instruction) to 18; the median age at first course on how pregnancies occur was 14, whereas for courses about HIV/AIDS, other STDs, and contraception, the median age was 15 (not shown). Lectures about HIV/AIDS, other STDs, and contraception are less prevalent than lectures on human reproduction by each successive birthday, but age at first lecture on these topics follows a pattern similar to that of lectures on human reproduction. The least taught topic is methods of birth control. The cumulative proportion of young women reporting formal instruction about this topic was 3% by age 14, 15% by age 15, 29% by age 16, and 36% by age 18 (see also Table 11.3.2). By each successive age, the probability of receiving contraceptive instruction is half the probability of receiving instruction about human reproduction. 199 200 201 Table 11.3.2 shows the cumulative percentage of women 15-24 who had received lectures in human reproduction and birth control methods by each successive birthday, by residence, region, and current age group. By all ages, urban residents were somewhat more likely than rural residents to have received formal instruction on these two topics. The residence differential narrows at older ages, suggesting a later start in school-based sex education in rural areas. For example, the proportion of urban women reporting formal instruction on human reproduction before age 15 is 44%, vs. 38% among rural residents, whereas 72% and 70%, respectively, have received such courses by age 18. There is little difference by region in the onset of courses about how pregnancies occur; the only notable exception is in the North region, where these courses appear to be intensified at age 17-18. For courses on contraceptive methods, however, residents of the South region reported slightly higher percentages at ages 16, 17, and 18. The lowest percentage by any given age was reported by residents of Transnistria, where these courses are almost never taught before age 14 and the likelihood of receiving instruction before age 18 is considerably lower (23%). Differences in the proportion of women who had courses about pregnancy and birth control by their current age highlight recent changes that seem to have occurred in school-based sex education. Teenage respondents (15-19 year-olds) were more likely to report these courses at any given age, with the gap widening for pregnancy instruction near completion of high school (at or after age 16). The age differentials are particularly important in contraceptive instruction; teenage girls were about 60% more likely to have such courses by any given age. The cumulative probabilities of receiving formal instruction about HIV/AIDS and other STDs by selected characteristics are shown in Table 11.3.3. Courses about HIV/AIDS were slightly more common among urban than among rural residents but the difference disappears by age 18. Conversely, courses about other STDs were slightly more common in rural areas. The regional differences show consistently lower probabilities of having instruction on HIV/AIDS and other STDs among young women in Transnistria at any given age. Teenage girls were also more likely than 20-24 year olds to have had courses on HIV/AIDS or other STDs, and the differences grew larger with the increase in age at first course. 11.4 Sex Education's Impact on Knowledge About Fertility Issues and Contraception Although almost all young women were exposed to at least one formal course of sex education (94%) and most of them had instruction about the menstrual cycle and how pregnancies occur (89% and 69%, respectively), taking a course does not necessarily translate into correct knowledge and subsequent safe sexual behaviors. To determine whether exposure to formal or parental sex education has any impact on respondents' knowledge of human reproduction, all young women were asked to identify the time during the menstrual cycle when conception is most likely to occur (they were read a list of five choices), if breastfeeding increases, decreases or has no effect on a woman's risk of getting pregnant, and if pregnancy can occur at first sexual intercourse. 202 Table 11.4.1 shows the percent distribution of young women according to their answers to these three questions by current age group and educational level. Knowledge of the most fertile time in a woman's menstrual cycle is an important measure of a woman's ability to assess the risk of pregnancy occurrence during unprotected intercourse, and thereby an indicator of her potential to prevent unintended pregnancies. Overall, only 39% of young women were able to correctly identify the most fertile time during a woman's menstrual cycle. The proportion with correct knowledge was almost twice as high for 20-24 year olds (52%) as for 15-19 year olds (29%) and the proportion saying they are not sure or do not know is only 5% among 20-24 year olds, compared with 20% among teenagers. Knowledge increased significantly with education, from 27% among respondents 203 with primary education, to 36% among those with some high school education, and 57% among high school graduates and university students. Knowledge about the contraceptive effect of breast- feeding was also low (28%) and increased with age ( from 21% among 15-19 year olds to 35% among 20-24 year-olds) and with educational level (from 23% among the least educated women to 33% among those with highest educational level). Knowledge that women can get pregnant at their first sexual relationship was far more widespread (70%) and also positively correlated with age and education. Differentials in knowledge about these three fertility issues by whether they ever had parental discussions on human reproduction or related school-based sex education are shown in Table 11.4.2. 204 Overall, discussions with parent(s) or sex education in school have only a weak influence on the proportion of young adults with correct answers. In the first panel, the proportion of respondents who knew the time during the menstrual cycle when the risk of pregnancy is highest was 36% among those who have never talked to a parent about this issue and 44% among those who reported such conversations. Similarly, for school based course-takers the correct answer was known by 40%, versus 38% among those who did not report formal instruction. Thus, the widespread exposure to this topic does not guarantee correct information, since most young adults who acknowledged education on the menstrual cycle either in school or at home gave the wrong answer and 13% did not know how to respond to the question. In the middle panel are responses to the question, "Do you think that breast-feeding increases, decreases or has no effect on a woman's risk of getting pregnant?" Overall, only about one in four young adults (28%) responded that breastfeeding decreases the risk: 31% among those who reported parental conversations about fertility and 29% among those who had formal instruction. There were 18% that said the risk was increased (fewer among those who reported sex education) and 28% did not know how to respond. Finally, in the bottom panel, young adults were asked if they agreed with the statement, "A woman can become pregnant the first time she has sexual intercourse." Sixteen percent did not think it was possible and 14% did not know. Again, parental discussions or sex education did not statistically affect the proportion of correct answers. Thus, neither formal instruction nor discussions with the parents about fertility issues has any statistically significant effect on correct knowledge about any of the issues explored. 205 The survey included a series of questions in which respondents were asked whether they knew how to use any of 10 methods of contraception listed (see also Chapter VI). As shown in Table 11.4.3, almost two-thirds of young women said they knew how a condom is used and only about half said they knew how withdrawal or the IUD was used. Less than 40% knew how other methods were used, with about one-fourth knowing how the pill or tubal ligation was used. Parental discussion appears to have a slight but consistent effect on knowledge of contraceptive method use. With the exception of withdrawal, those who received contraceptive education in school had consistent, but not significantly better, knowledge on how contraceptive methods are used. In summary, even though 34% of young adults reported having been taught sex education in school before they were 18 years of age, the results cast a dark shadow on the quality of the sex education curriculum. Parental discussion about contraceptive methods also did not have a significant impact on knowledge. Opinions of young adults about contraceptive effectiveness and risks of side effects are shown in Tables 11.4.4 and 11.4.5. About half said that the Condom (52%), tubal ligation (47%) and the IUD (46%) are highly effective in preventing pregnancy. Almost one-half (46%) did not know anything about the effectiveness of tubal ligation. Parental discussion or sex education about contraception did not affect responses about contraceptive effectiveness. Forty percent of young women did not have any opinion on the effectiveness of oral contraceptives. All women were asked to rate each of the five modern contraceptive methods mostly used in Moldova (IUD, condom, pills, tubal ligation, and injectables) with regard to effectiveness and safety (see also Chapter VII). Women could rank each method as having low, medium or high effectiveness or risk of side effects. Opinions about contraceptive effectiveness among young women are shown in Table 11.4.4. The IUD and condom were the only two methods about which majority of respondents had an opinion regarding use-effectiveness. However, the condom was perceived as very effective by the highest proportion of young women (52%), whereas the IUD was considered very effective by only 46% of women and the pill by only 22%. For oral contraceptives, tubal ligation and injectables, from one-third to two-thirds did not know enough about the method to give an opinion. For withdrawal, about one in three young women said the method is very effective or moderately effective but another third did not know how to rank it. As shown in Table 11.4.5, young adults' opinions about contraception safety follow a similar pattern. The condom was ranked very safe by 72% of respondents, whereas the IUD and the pill were considered safe by only 20% and 16%, respectively. Between one in six and one in five women considered the use of pills and IUD completely unsafe. Moreover, between one- and two-thirds of women could not express an opinion about the other methods. Again, parental or school-based sex education about contraception does not have any effect on opinions about contraceptive effectiveness and safety. Obviously, education on the benefits and risks of contraception needs to be improved, not only in the sex education curriculum but also in the counseling given in women's clinics and adolescent clinics. 206 207 208 CHAPTER XII SEXUAL AND CONTRACEPTIVE BEHAVIOR AMONG YOUNG ADULTS In traditional, predominantly rural societies, it is the norm for women to marry and start their childbearing at young ages. Consequently, young wives and mothers in these settings generally have the economic and social support of their families and communities. However, traditional norms are weakening; the forces of modernization-urbanization, rising educational attainment, more exposure to the mass media, and changes in the status of women have altered every aspect of life, including the age patterns of sexual activity, marriage, and motherhood. Thus, information was needed to describe these recent patterns and to design intervention programs to meet the needs of young women in a time of significant changes. Survey findings presented here may underestimate the true extent of social and behavioral changes that have occurred recently among young adults, since sex before marriage and nonmarital pregnancies may be under-reported in countries where strong traditions view premarital sex as morally wrong and condemn childbearing out of wedlock. 12.1 Sexual Experience The MRHS questionnaire included a series of questions regarding the age at which young women became sexually active, relationship to their first sex partner, contraceptive use at first intercourse, lifetime and current (within the last three months) number of sex partners, and communication with their partners concerning contraception. As shown in Tables 12.1.1 and Figure 12.1.1, slightly less than half of 15-24 year-old women have ever had sexual intercourse. While the likelihood of having had intercourse increases steadily with age, sexual activity among very young females is uncommon. Only 10% of 15-17 year old women have ever had sex. In fact, even later in the teenage years (18-19), less than one in two girls is sexually experienced. Overall, almost 80% of teenage girls were virgins (see also Table 12.1.2). Conversely, sexual experience is very common among 20-24 year-olds. Two out of three 20 year- old women, five out of six 21-22 year-old women, and almost all women (91%) aged 23 and over were sexually experienced. 209 Although sexual abstinence before marriage is still common in Moldova, 14% of 15-19 year- olds and 40% of women aged 20-24 years have had intercourse before marriage (Table 12.1.2 and Figure 12.1.2). A comparison of age at first sexual intercourse among women aged 20-24 with older five-year age cohorts indicated that a growing proportion of women have become sexually experienced by age 16, 18, and 20 (not shown). Among 20-24 year-old respondents, 4% reported sexual activity by age 16 compared to only one percent among women 30 years of age or older. Likewise, by age 18, there was an almost three-fold increase in sexual experience among women aged 20-24 years compared to women aged 30 years or older (29% vs. 11%). Overall, slightly more than half of women reporting sexual experience had premarital sexual intercourse. However, among sexually experienced women, the proportions who initiated sexual activity before marriage was inversely correlated with current age. Sexually experienced adolescents were more likely to report premarital sex than 20-24 year-olds. About two out of three sexually experienced women aged 15-19 were not married when they first had sex, compared to one out of two women aged 20-24. 210 211 The level of sexual experience among different subgroups ranged from 40% to 55% and the level of premarital intercourse ranged from 18% to 36% (not shown). Women in urban areas, residents of Chisinau and Transnistria, women with a post high-school education and those living in households with high socioeconomic status were more likely to have had their first sexual relationship before marriage. Although the level of sexual experience was similar among various ethnic groups, young women of Russian and Ukrainian background reported a much higher 212 Prevalence of premarital sexual intercourse (33% and 36%, respectively) with ratios of premarital to marital intercourse of 2 to 1 and 1.5 to 1. Young adults' sexual experience by marital status at the time of first sexual experience is shown by strata in Table 12.1.2. The overall levels of sexual experience were not significantly different in urban and in rural areas. However, slightly more adolescent women residing in the four municipalities reported sexual experience (25%) than those residing in other urban or rural areas (19%). Also, the levels of premarital intercourse appear to be considerably higher among young women in municipalities, regardless of their current age. Virtually all sexually experienced 15-19 year olds and two-thirds of 20-24 year olds residing in municipalities reported they had not been married at the time of first intercourse. By comparison, in other urban areas only 61% of adolescents and half of young women had had premarital intercourse, whereas in rural areas only slightly more than one-half of teenagers and 35% of 20-24 year olds reported sex outside marriage. Several factors could have contributed to the differences in premarital sex between urban and rural residents. First, women in rural areas are more likely to marry at younger ages; 13% of rural teenagers and 81% of 20-24 year olds were currently or previously in a marital relationship, compared with 12% of 15-19 year-old women and 73% of 20-24 year-olds in other urban areas and 10% of 15-19 year olds and 59% of 20-24 year olds in municipalities who have ever been married (not shown). Second, rural young women are more likely to grow up in families with strong traditional values. Stronger family ties, parental control of dating, stricter upbringing, and a higher emphasis on virginity at first marriage are more common in rural areas. Third, young women in rural areas are more likely to be influenced by community and religious restraints than those who grow up in urban areas. Final, young women in rural areas are less likely to work outside the house, which also may contribute to less independence and control of their reproductive lives compared with urban women. Differentials in age at first intercourse among different subgroups of young women is illustrated in Table 12.1.3. Generally, the onset of intercourse is rather late among young women in Moldova. Overall, the proportion who initiate sexual activity before age 16 is low (5%) and increases to 27% among women less than 18 years of age and to 63% before age 20. Proportions having had intercourse before ages 16 and 18 were slightly higher among young women living in municipalities (7% and 30%) than among those living in other urban areas (3% and 28%) or in rural areas (4% and 26%). They were also slightly higher for women residing in Chisinau and the Northern region of the country. Residents of Transnistria had also a higher probability of intercourse before age 18 (29%) and before age 20 (66%). 213 Education was a strong bi-variate predictor of delayed sexual activity among young women. Women with post high-school education were the least likely to have had sex before any given age. Only 3% and 19%, respectively, had intercourse before ages 16 and 18. The probability of sexual intercourse before these ages was highest for women with less than ten years of schooling (7% and 37%). These findings have important implications for sex education efforts, which routinely target high-school students. If all young women are be taught about using contraception before they 214 initiate sexual activity, age-appropriate sex education programs need to begin in elementary school. The patterns of first intercourse also differ by socio-economic status. Young women of low socio-economic status were more likely to be sexually experienced before age 16 (7%) and 18 (33%) compared with women of middle or high status (4% and 25%, and 3% and 30%, respectively). However, the socio-economic differences are likely to reflect, in part, differences in education, as less well educated women are more likely to be poor. Although the numbers are small and have to be viewed with caution, young women of Ukrainian background were slightly more likely to be sexually experienced before age 18 but, by age 20, there was no significant difference in sexual experience by ethnicity. 12.2 Current 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. 215 Table 12.2 shows the overall sexual activity status among young women. Notably, only 38% of all young women had had intercourse within the last three months (i.e., currently sexually active). However, if we limit the analysis of sexual activity status only to those who have ever had sex (see Figure 12.2), 76% of the sexually experienced females had intercourse during the three months preceding the survey and 12% are in the pregnant/postpartum category. As shown in Table 12.2, women who were in legal or consensual unions were much more likely to be currently sexually active than noncohabitating young women (81% vs. 13%). Almost one in seven young women were either pregnant or in the postpartum period whereas almost none of those not currently married reported being pregnant or postpartum. Table 12.2 also illustrates sexual activity status among adolescents and 20-24 year olds. As expected, fewer teenagers reported current sexual activity. Only 11 % of teen females reported having had sex within the previous 3 months. By comparison, 60% of 20-24 year-old females were currently sexually active. However, if we look only at sexually experienced young adults, age differences in reports of current sexual activity narrow substantially (Figure 12.2): 65% of teenagers compared to 80% of 20-24 year-olds were currently sexually active. 216 12.3 Contraceptive Use at First Sexual Intercourse Contraceptive behavior at first sexual intercourse is an important indicator of the risks of unintended pregnancy and STDs. Studies in the United States have shown that the risk of pregnancy among young women is highest in the few months following the first coitus (Zabin LS, et al., 1979), and their chance of acquiring a sexually transmitted disease during a single unprotected intercourse with an infected partner ranges from 1 % for HIV to 30% for genital herpes, 40% for chlamydia, and 50% for gonorrhea (Harlap S. et al., 1991). Contraceptive use at first intercourse can also predict future contraceptive behaviors, such as continuation of use. Most young people who have used contraception the first time they had sex were also using it at the most recent intercourse (Mauldon J.and Luker K., 1996). For these reasons, it was important to know whether the 50% of young women who reported sexual experience had used a contraceptive method at the time of their first intercourse. Because contraceptive behavior is very different depending on whether the onset of sexual activity precedes marriage, contraceptive use is reported separately according to whether first intercourse was 217 premarital or marital. Data collected in the MRHS show a very low prevalence of contraceptive use at first intercourse and heavy reliance on withdrawal and, to a much lesser extent, on condoms (see Table 12.3.1 and Figure 12.3). More than half of those using a method relied on withdrawal and about one in three had used condoms. The likelihood of using a method was lower among women whose first intercourse was marital (18%) and higher among sexually experienced young women who reported premarital intercourse (33%). The contraceptive method mix at first intercourse was also related to marital status at first intercourse. While the most prevalent method continues to be withdrawal, regardless of marital status, the proportion of condom users was four times higher among women who were not married at first intercourse (13% vs. 3%). 218 Contraceptive use at first intercourse also varied by residence (Table 12.3.2). Overall, the contraceptive use of young women living in urban areas was higher than for women living in rural areas, independent of marital status (25% vs. 14% and 40% vs. 21% for married and unmarried women, respectively). Also, the use of modern methods was higher in urban than in rural areas (7% vs. 2% and 19% and 5%, respectively) but traditional methods prevailed regardless of the residence and marital status. However, the use of modern methods as a proportion of total contraceptive use was remarkably higher (19% corresponding to almost 50% of total contraceptors) among unmarried urban women compared with married women in urban areas or rural women. 219 Contraceptive use at first intercourse varied slightly among different ethnic groups (see Table 12.3.3). It was higher among women of Russian or Ukrainian ethnic background (32% and 34%, respectively) than among Moldovan (24%) or women of other ethnic groups (18%). Contraceptive method mix was also influenced by ethnic background. Condom use was more prevalent among Russian and Ukrainian women (18% and 13%), among whom it was the most common method (it was used as commonly as withdrawal in Ukrainians). Withdrawal was the most common method among Moldovan young women (16%) and women of other ethnicities (8%), representing two-thirds and almost half, respectively, of their contraceptive prevalence at first intercourse. 220 The study of contraceptive use at first intercourse indicates a heavy reliance on male- controlled methods, suggesting little involvement of young women in decisions about contraceptive method choice at first intercourse. Indeed, only slightly over a third of young women have talked to their partners about contraceptive use prior to their first sexual relationship (not shown). However, when these discussions did occur, couples were five times as likely to have used a method as those who had no prior conversation about contraceptive use (52% vs 10%), but they were equally likely to use either withdrawal or condoms as their first method. Several factors may have contributed to this lack of assertiveness among young women. First, the older age of male partners may give them more influence in contraceptive decision-making; the MRHS showed that many young women with premarital intercourse had their first intercourse with older partners (45%), half of whom were three or more years senior to them. Second, communication and agreements may be difficult to achieve for young women; only a third of sexually active women who have used contraception at first intercourse said that they were in agreement with their partner to use a method, whereas almost half said it was a "partner-only" decision. • In both instances, however, the decision was to use primarily withdrawal, followed by the condom. Among the very few women who decided to use a method without consulting their partner, the method used was either the calendar or the pill. Third, high condom use at first intercourse may suggest greater concern with preventing STDs, but also may be due to greater availability of and accessibility to an over-the-counter method. Since young couples in Moldova rely overwhelmingly on male-controlled methods, more efforts should be made to educate young men about other effective methods of contraception. If they are not in monogamous relationships, young men should continue to use condoms to prevent STDs together with the partner using a more effective method to prevent pregnancy. Furthermore, education messages should seek to improve negotiation skills and assertiveness among young women, to enable them to play an active role in contraceptive decision-making. 12.4 Reasons for Not Using Contraception At the Time of First Sexual Intercourse As shown in Table 12.4.1, among young women who had not used contraception at first intercourse, the most common reason for not using a method was personal desire to get pregnant (41%), followed by lack of concern about contraception (20%), followed closely by unexpected sexual intercourse (20%). Personal or partner opposition to contraceptive methods was mentioned by only 9% and 3%, respectively, and little knowledge about contraception by only 4%. Other reasons, including perceived safe time of the month and the cost associated with contraceptive methods, played minor roles in the decision not to use contraception (2%). 221 Reasons for not using contraception are strongly affected by marital status. Table 12.4.1 shows that among women whose first intercourse was marital, the desire for pregnancy played a larger role in their decision not to use contraception compared with those who had premarital intercourse (59% vs. 19%). For women who had premarital intercourse, the leading reasons were unexpected sexual intercourse (29%) and lack of concern for contraception (28%). Among all young women with sexual experience, the main reason not to use contraception was also influenced by their age at first sexual intercourse (Table 12.4.2). Personal desire to get pregnant was positively correlated with age at first intercourse; the proportion of women who gave this reason was 29% among those with sexual experience before age 18 and nearly doubled among 222 those whose first intercourse was between 20-24 years of age. Lack of concern about contraception, unexpected sexual intercourse, and lack of knowledge about contraception were inversely correlated with age at first sex. These results have important implications for the development of interventions. They make it clear that many young adults are apparently not concerned about the risk of unprotected intercourse and do not have accurate information on contraception. These youth could benefit tremendously from comprehensive sex education programs in schools. In addition, for those who actually oppose contraception, programs will need to emphasize other benefits of contraceptive use, such as protection against HIV and other STDs. 223 12.5 Use of Contraception at Most Recent Sexual Intercourse As shown previously, not all young women who have ever had intercourse were currently sexually active and in need of contraception. Since most young adults not involved in a marital or cohabitation relationship may be temporarily sexually inactive for varying lengths of time, their current contraceptive status is difficult to assess accurately. Instead, a better measure of their ability to protect against unintended pregnancy and STDs is contraceptive use at most recent sexual intercourse. 224 As shown in Table 12.5, among sexually experienced young women, regardless of the timing of their last sexual intercourse, contraceptive prevalence on that occasion was relatively high (75%). Furthermore, contraceptive use at last intercourse was more likely to be a modern method rather than a traditional method. The ratio of modern to traditional methods use was 1.6:1. However, the most prevalent method was withdrawal, used by 27% of couples, followed by IUD (22%) and condom (19%). Patterns of contraceptive use at last intercourse were strongly influenced by marital status. Overall, the contraceptive use was significantly higher (p<0.05) among women in legal or consensual marriages than among those not currently married (78% vs. 66%). The greater use among married women was the result of proportionally higher usage of both modern and traditional methods but the ratio of modem to traditional methods was similar to that for unmarried women (1.6 to 1 and 1:5 to 1). IUD use was much higher among married women (27%) than among unmarried women (7%), whereas the use of condoms was almost twice as high for unmarried as for married women (28% vs. 15%). Withdrawal use did not vary substantially by marital status. 12.6 Opinions and Attitudes About Condoms and Condom Use In addition to the perceived effectiveness of condoms described in Chapter 6, other attitudes and beliefs associated with condom use among young adults were explored (Table 12.6.1). These associations were explored by asking women aged 15-24, regardless of their sexual experience or condom experience, whether they agree or disagree with selected statements about condoms. However, since young adults without sexual experience cannot have had condom experience and, therefore, could not formulate an opinion about certain statements regarding condom use, the results are shown for only sexually experienced women. Table 12.6.1 shows sexually experienced respondent's beliefs about condoms and condom use by ever users and never users of condoms. The first overall result that one observes is that never users are much more likely in response to most statements shown to not agree or disagree because of their lack of experience with condoms. For 9 of the 13 statements, at least 15% of never users replied "don't know" and for seven statements, more than one-fifth could not give an answer. This is especially true for the first two statements which are obviously impossible to answer without personal knowledge. 225 There are five statements where responses of users and non-users are quite similar. Most young women did not agree that condoms can be used more than once ( 98% and 89%, respectively). Questions that explored the social or physical acceptance of condoms showed the most respondents, regardless of their condom experience, agreed that "most women do not like to use condoms" ( 70% of ever users and 72% of never users) or that "most men do not like to use condoms" ( 75% and 70%, respectively). Most agree that using condoms with a new partner is a good idea ( 93% and 80%, respectively) but only about one-half of both groups agree that" if you know your partner, it is not necessary to use condoms". 226 Almost 60% of ever users agree that "condoms reduce sexual pleasure" and one-half agree that "condoms are messy". Thus, a great many condom users use them for protection even though they would rather not use them. Ever-users are also quite knowledgeable (70%) about "condoms requiring one's partner to have self control". Questions asked to explore beliefs concerning embarrassment in purchasing condoms or obtaining them from clinics showed that females that have ever used condoms were significantly less likely than never users to agree that "it is embarrassing to buy condoms in a pharmacy or store" ( 28% vs 46%) or " to ask for condoms in a clinic" (25% vs 44%). A greater proportion of young adults who have never used condoms associate the use of condoms with " sleeping around a lot" ( 39% vs . 17%). Finally, the majority of ever users agree that women should ask their partners to use condoms ( 64% vs. 49%) and "it is easy to discuss condom use with a prospective partner" (60% vs. 38%). Table 12.6.2 shows the percentage of sexually experienced young women who have ever talked to a partner about his using condoms, by their condom experience. Overall, slightly more than half have talked to a prospective partner about his using a condom. It is not surprising that almost all (96%) of those who ever used a condom have discussed it with a partner while only 29% of never users have discussed condom use with a partner and were obviously unsuccessful. Young women who have unsuccessfully discussed condom use tend to be urban, living in Chisinau, not married, better educated and non-Moldovan. Looking at the other way around, if a young woman had ever talked to a partner about using a condom, almost two-thirds (65%) have used a condom; if she had never talked to a partner, only 3% reported that they have ever used a condom ( data not shown in table). Thus, it appears that young women in Moldova cannot depend on their partner to use a condom unless they initiate discussions with him. Most young adults (over 87%), and almost all of those who have ever used condoms (over 92%), expressed positive feelings of protection (i.e., feeling of being protected from pregnancy and STDs, including AIDS) if their partners would want to use condoms (see Table 12.6.3 and Figure 12.6). Also, few women expressed "negative feelings" about a partner's desire to use condoms, such as embarrassment (33%), anger (24%) or guilt (21%). These "negative feelings" were more likely to be associated with rural women, women who live in the Central region, married women, less educated women, and by those who have never talked to a partner about condoms, those who do not know how condoms are used, and those who have never used condoms. 227 228 229 230 CHAPTER XIII HEALTH BEHAVIORS 13.1 Cigarette Smoking Tobacco is a potent human carcinogen that has been shown to be related to a significant number of cancers of the respiratory and digestive tracts, bladder, cervix and kidney. Cigarette smoking accounts for 87% of lung cancer deaths, and 30% of all cancer deaths. Smoking is also a risk factor for atherosclerosis—the clogging of the blood vessels with fat and cholesterol—which is a major risk factor for heart attacks, strokes and blood clots of the legs and lungs. Smoking also contributes to the large number of people with asthma, emphysema, pneumonia, and osteoporosis. Maternal smoking has been linked to low birth weight babies, pre-term deliveries, miscarriages, sudden infant death syndrome, and respiratory problems of infants exposed to "passive smoking" (DiFranza &Lew RA, 1996). Smoking is the most important modifiable cause of death, responsible annually for over 400,000 deaths among adults in the United States, which represent an estimated five million years of potential life lost (CDC, 1993). The U.S. Preventive Services Task Force reports that "estimated smoking-attributable costs for medical care in 1993 were $50 billion, and excess lifetime medical expenditures for the current cohort of smokers may be as high as $500 billion dollars'1 (US Preventive Services Task Force, 1996). One of the national health objectives related to smoking in the United States is to reduce smoking to a general prevalence of no more than 15% among people 20 years of age or older and 12% among women of reproductive age. Another objective is to decrease the initiation of smoking to no more than 15% among youth under age 20. Tobacco use in Eastern Europe has steadily increased since 1990, owing mostly to the transition toward a market economy and the arrival of the international tobacco industry, whose advertising campaigns have thrived in the absence of legislative regulations. Recent population- based surveys of reproductive health conducted in Central and Eastern Europe documented that smoking prevalence among reproductive age women ranges from 30% in Czech Republic (Goldberg et al., 1995), to 25% in Russia (Goldberg et al., 1998), to 22% in Romania (Serbanescu et al., 1995). Additional data about tobacco use among youth in Romania have shown a sharp increase in prevalence among young women (from 15% to 20%) and a prevalence of 47% among young men (Serbanescu et al., 1998). In Moldova, however, tobacco use seems to be far less widespread. The 1997 MRHS included two questions for determining cigarette smoking status: "Have you smoked at least 100 cigarettes in your entire life?" and, for those who ever smoked 100 cigarettes, "During 231 232 the last 30 days did you smoke every day, almost every day, some days, or not at all?" As shown in Table 13.1, only 7% of women have reported smoking at least 100 cigarettes during their lifetime (ever smokers) and only 6% have smoked daily during the 30 days preceding the survey (current smokers). In addition, 20% of women reported they have ever smoked cigarettes but less than 100 cigarettes during their lifetimes (data not shown). Women residing in urban areas were eight times as likely as rural young women to have ever smoked and to be current smokers. The highest percentage of past and current smokers reside in Chisinau (14% and 12%, respectively) and in Transnistria (9% and 8%, respectively). The rates of past and current smoking among women residing in the Central, South and North regions were similar and very low. Smoking experience was inversely correlated with age, with the prevalence of smoking being about twice as high among those aged 15-24 and 25-34 years of age as among women aged 35-44. Previously married women were much more likely than those currently married or unmarried to have ever smoked (14% vs.5% and 7%, respectively) or to smoke currently (13% vs. 5% and 6%, respectively). Smoking did not vary significantly by educational attainment but it was slightly more prevalent among women with high socioeconomic status (SES) and those currently employed. Moldovan women were the least 233 likely to report either past or current smoking (4% and 3%), whereas women of Russian ethnic background were almost five times as likely as Moldovans to be past or current smokers (15% and 13%). Among current smokers, 40% smoked six or more cigarettes daily, including 11% who smoked more than a half a pack daily. Figure 13.1 shows that by age 18, about one in ten teenagers has tried to smoke but only 3% smoked regularly. Most of the youth who initiated smoking did so by age 25, when 21% of young women have smoked at least once. However, very few become regular smokers (7%). The cumulative life-table probability of regular smoking almost doubles between age 20 and 25 (from 4% to 7%) but levels out by age 30 (8%). 13.2 Alcohol Use Alcohol use has been shown to be associated with risky sexual behaviors, violence, and academic problems among youth (DJ Hanson and RC Engs, 1992). Alcohol abuse among women of reproductive age has significance beyond its potential harm to the individual because of the potential damage to their fetus or children. No one knows how much alcohol it takes to harm a fetus, or if any mothers can drink safely. However, it is known that the more alcohol a pregnant woman drinks, the greater the chances of birth defects (fetal alcohol syndrome). Even "social drinking" may cause minor developmental problems in an otherwise normal baby. Although alcohol consumption is perceived to be high in Moldova, no other studies have assessed alcohol use in a national sample. Official statistics indicate that 20% of chronic drinkers are women, including 13% of women of reproductive age (UNICEF, Status of Mother and Child in Republic of Moldova, 1997). The 1997 MRHS is the first representative sample to address this issue among reproductive age women. Alcohol use was measured by asking each respondent how many drinks they had at any given occasion during the past three months, and how often they drank that amount. Respondents who have had at least one drink per month were considered "current drinkers"; those who had at least one drink every day or almost every day were defined as "current frequent drinkers"; and those who consumed four or more drinks in a row at any given time during the three months preceding the survey were defined as "episodic heavy drinkers." Results show that approximately one in two women drank alcohol within the three months preceding the survey (53%) and 43% have used alcohol every month (Table 13.2). Current frequent use was slightly higher among rural than among urban residents (19% vs. 14%), and among residents of the South and Central regions (21% and 20%) and in Transnistria (21%). It was directly correlated with age (with 9% of 20-24 year-olds reporting current frequent use vs. 19% among 234 235 women aged 25-34 and 22% among 35-44 year olds) and higher among previously and currently married women (21% and 19%, respectively). Current frequent use was somewhat lower among women with the highest educational attainment and among those classified with a medium or high SES. About one in twelve women (8%) reported current episodic heavy drinking (four of more drinks of alcohol on at least one occasion within the last three months). Episodic heavy drinking was consistent with the pattern for current frequent drinking. It was slightly higher among women in the Central and South regions and in Transnistria, among older women, those previously or currently married, and those with lower education levels and low SES. 13.3 Prevalence of Routine Gynecologic Visits Among Sexually Experienced Women Patient attitudes and behaviors regarding health care visits are important determinants of whether they receive routine screening, including cervical and breast cancer screening, and whether they receive appropriate counseling for family planning and STD prevention. Important barriers that can prevent individual accessibility to routine health visits include: perceived lack of susceptibility to disease, no knowledge about benefits of screening, perceived discomfort of screening, fear of positive results, fatalistic attitudes toward illness and fear of potential treatment. Lack of knowledge of health-related issues, noncompliance with doctor's recommendations, miscommunication between patient and provider, and socio-economic and geographic factors are also other potential barriers. Other factors limiting access to preventive health care visits include limited resources within the health system, inadequate and/or maldistribution of health providers, and physician barriers (knowledge, attitudes and beliefs regarding routine screening, lack of time or expertise, restrictive hours of service availability). It is recommended that women of reproductive age have a routine gynecologic examination every year. The 1997 survey (Table 13.3.1) shows that more than two-thirds (70%) of sexually experienced women had been examined by a gynecologist during the previous 12 months. Most of the women who had not undergone an exam within the past year reported an exam within the past three years (19%). Thus, 89% of sexually experienced women had seen a gynecologist within the last three years. Only 7% have never had a gynecologic exam. Rural residents, women living in the South, younger women, previously married and never-married women, mothers with four or more children, women with lower levels of education, and those of "other" ethnicity were more likely to have never received preventive gynecologic exams. Such a high prevalence of routine exams offers a good opportunity for screening, counseling, and health education. 236 237 The reasons for not seeking routine gynecologic exams are important to study because they may uncover potential barriers to the use of preventive health services. Most women (57%) who have never had a routine exam believed they did not need one because they have no health complaints (50%) or that it is unnecessary to have routine check-ups (7%). These women are probably lacking general health education and are unaware of the screening procedures and/or the health benefits of screening. The second most common reason was lack of enough commitment or time to have a check-up (26%), followed by fear of discomfort, including pain and embarrassment associated with gynecologic check-ups (7%). Few women said they neglected to see a gynecologist (4%) or that they never thought to go to such visits (2%); very few claimed that the health providers did not recommend such exams, the waiting time was too long, or that they cannot pay for such services. These findings demonstrate that, although the majority of women have access to routine gynecologic exams to achieve effective preventive health services for all reproductive age women, continuous efforts should be made to modify general health beliefs and attitudes and to educate women about screening procedures and disease prevention. 238 13.4 Breast Self-Exam Secondary prevention of gynecologic neoplasms has been proved effective only for breast and cervical cancers. Methods for early detection which can reduce breast cancer mortality include breast sell-examination (BSE), breast physical exam performed by physicians, and mammography (Last et. al., 1986). In populations where mammography is not readily available or is too expensive (and thus unsuitable for to be used in screening), BSE and medical exams can reduce breast cancer mortality if they are performed correctly and consistently. BSE is a very simple self-care procedure that can detect early modifications of the breast and can be performed by women in the privacy of their homes after minimal instruction. Appropriate follow-up by a physician should be available and accessible for women who detect breast changes through self examination. The 1997 MRHS explored only the level of awareness about BSE and its prevalence, without any indication of proficiency in BSE performance. Overall, two-thirds of women of childbearing age have ever heard about this technique (data not shown) but only half (52%) have ever performed BSE (see Table 13.4). Awareness of BSE was higher among urban than among rural residents (70% vs. 60%), among women residing in Chisinau (69%), those aged 25-34 (72%) or 35-44 (74%), among women currently or previously married (71% and 67%, respectively), those with post- secondary education (78%) or high SES (75%). Although awareness of BSE was significantly higher among those who underwent routine gynecological exams, compared with those who never had such exams (67% vs 40%), it is surprising that one in three women who have routinely seen a gynecologist is not aware of BSE and only 51% had performed the exam. Table 13.4 shows the prevalence of this practice among sexually experienced women and the frequency of performing BSE. Overall only one in two women practices BSE and only one in three performs BSE every month. Both prevalence of BSE and monthly practice of the exam were higher among those who underwent routine gynecologic exams within the last year, compared with women without routine visits to a gynecologist (51 % vs. 31% and 37% vs. 23%) but the differences were not significant if the routine exam took place two or more years ago. However, two-thirds of women who had a gynecological visit within the past 12 months did not report routine BSE, which suggests that this preventive practice is not properly covered by health care providers. Women who never used BSE were more likely to live in rural areas than in urban areas (55% vs. 49%), to be young adults (68%), to be unmarried (71%), childless (65%) or with four or more children (66%), and to have not completed secondary education (65%). Russian women were slightly more likely to use BSE (54%) than Moldovan and Ukrainian women or women of other ethnic background (not shown). 239 240 13.5 Cervical Cancer Screening Cervical cancer is the second most common cancer among women, with almost 450,000 new cases diagnosed each year worldwide (World Health Organization, 1993). However, it is the most frequent cancer of women in developing countries, where 80% of cervical cancers are diagnosed (Parkin DM, et al., 1993). Age-adjusted incidence rates range from 5-42 cases per 100,000 women, with high rates in Latin America, Africa, Southeast Asia and lower rates in North America, Western Europe, Australia, and Israel. The cervical cancer rate in Moldova is not available, but the average rate for Eastern Europe—21.6 cases per 100,000— is 33% higher than the Western European average of 15.0 per 100,000. Mortality due to cancer of the cervix constitutes the third leading cause of death among women in Romania, while in Poland, Hungary, Ukraine, Czech Republic, Russian Federation, and Belarus it ranked the fifth, eighth, 11th, 12th, 16th, and 22th, respectively (Parker SL et al., 1996). The mortality rate from cervical cancer in Moldova also is not available. In developed countries the incidence of in situ cervical cancer is increasing, whereas invasive cancer and cervical cancer mortality are declining. Much of the decline in mortality has been attributed to widespread use of cervical cancer screening (Papanicolau smear test). The decrease in mortality results from detection of cancer at an earlier and therefore more curable stage and the detection and treatment of premalignant lesions. Data from large screening programs have shown that annual Pap smear screening reduces the probability of developing invasive cancer by 93.3%, whereas screening every three years reduces the probability by 91.2%, and screening every live years reduces it by 83.6% (Miller AB, 1986). Based on these estimates, most experts recommend that women who are sexually active or at least 18 years old should have a Pap test annually or every three years, followed by the option of reducing the frequency of screening in women over age 65 who have been regularly screened with normal results. Risk factors for cervical cancer include a history of multiple sexual partners, early onset of sexual intercourse, smoking, infection with the human immunodeficiency virus and infection with a certain serotype of the human papilloma virus. Although the validity of self-reported rates of Pap testing cannot be established without examining medical records, survey results are often used to estimate the extent of cervical screening in the general population. The 1997 MRHS included a series of questions for female respondents regarding Pap test history: "Have you ever had a cervical smear test (Papanicolau screening test)?'', "When did you have your last cervical smear test?", and, for those who have never had a test, "What is the main reason you have never had a Pap smear?" 241 242 Overall, only 43% of sexually experienced women reported that they had ever had a Pap smear (Table 13.5) and only 35% had their last test within the past three years. Although low, the proportion of women who have had a Pap test was slightly higher in urban areas than in rural areas (45% vs. 40%) and among women residing in Chisinau (48%). Geographic differentials indicate that many women have reduced access to cancer screening, due probably to uneven distribution of primary health care providers, unavailability of local screening facilities, geographical location, transportation, and/or cultural barriers. Prevalence of cervical cancer screening was directly correlated with age (from 21% among 15-24 year olds to 45% among 25-34 year olds and 52% among women aged 35 or older) and with educational attainment, ranging from 34% among women who did not complete secondary education to 49% among those with postgraduate education. The proportion of respondents having a Pap test increased with SES (not shown) and with the number of living children. Far fewer sexually experienced childless women reported that they have ever had Pap screening (26%), compared with women with one child (42%) or with two or more children (47%), due, in part, to the fact that cervical screening is mandatory during antenatal care. Women who have never used contraception (not shown) were slightly less likely to have ever had Pap test (36%), compared with current or past users (44% and 41%, respectively). Prevalence of Pap smear tests was directly correlated with frequency of gynecologic exams, ranging from 6% among women who have never had a routine exam to 47% among those with annual visits. It is worth noting, however, that only approximately half of women seeking routine gynecologic exams were screened for cervical cancer, in spite of their eligibility (sexually experienced women). Gynecologic routine visits should be viewed as opportunities to educate patients about healthy lifestyle choices and to promote appropriate screening for preventable diseases such as cervical cancer. Lack of time and of financial incentives, lack of provider knowledge and interest in preventive care, lack of patient knowledge, and a poorly developed screening system are major contributors to the low coverage of cervical cancer screening. As long as health care providers do not engage actively in the delivery of preventive care in Moldova, screening for cervical cancer will remain unsatisfactory, with costly consequences for an already burdened health delivery system. Figure 13.5 presents the most important reasons for not having a cervical cancer screening test. For 40% of respondents the most important reason was the lack of a recommendation of the test by a health provider. As with routine gynecologic exams, many women who have never had a Pap smear believe they do not need to have one (31%). Interestingly, the third most common reason was lack of knowledge of such a screening; 23% of women have never heard of Pap test. 243 About 5% of respondents reported that the most important reason they have not had screening was that they could not find time to visit the physician. These findings reiterate the lack of awareness of gynecologic screening procedures among reproductive age women in Moldova and the need for sustained educational campaigns for the public and changes in the practice of health care providers. 13.6 Prevalence of Selected Health Problems Among Women of Reproductive Age All respondents were asked "Has a doctor ever told you that you have had (selected health problems)?" These problems were: anemia, urinary infection, infection of the tubes or uterus, high blood pressure, heart disease, hepatitis B, asthma, and diabetes. Table 13.6 and Figure 13.6 show the percentage of women who have ever been told by a doctor that they have had these specific health problems. 244 245 Obviously, these results are minimum estimates of the true prevalence of these health problems in the population of women of childbearing age. They probably under-represent the real prevalence since self-reporting of health conditions implies that young women had access to health care facilities, had visited these facilities, and had been told by physicians about their health. Thus, the self-reported occurrence of health problems among different subgroups should be interpreted with caution because background characteristics may affect both the access to health care system and reporting. Furthermore, these are lifetime estimates, do not reflect current health status and cannot be temporally associated with other events. For example, a direct link between anemia and pregnancy cannot be established since is impossible to determine if anemia was a prior condition or had developed during the pregnancy. For all these reasons, the survey data about health problems among 246 women may serve only as proxy estimates in the absence of official statistics based on medical records or hospital discharge data. The most common condition reported was a genital tract infection. The prevalence of genital tract infection or pelvic inflammatory disease (PID) was determined by asking women if they had ever been told that they had an infection of the fallopian tubes (salpingitis) or infection of the uterus (endometritis). Overall, 21% of all women reported PID. Those most likely to report PID were women in urban areas, including Chisinau (24%), women aged 25-34 years (27%) or 35-44 years (29%), women with two or more children, women with a post-secondary education (26%) and high SES (24%), and working women (25%). PID was almost non-existent among virgins and increased steadily with the number of lifetime sexual partners, from 23% among monogamous women to 37% among those with four or more sexual partners. Overall, almost one in every five women (19%) reported she had been told by a doctor that she had anemia. Women living in Transnistria were far less likely to report anemia (7%) compared with women living in other regions. The prevalence of anemia was higher for older women—14% among 15-24 year-olds, 24% among women aged 25-34, and 20% among 35-44 year-olds. The prevalence of anemia was significantly higher among sexually experienced women than among those who never had sexual intercourse (22% vs. 7%) and it was positively correlated with educational level, ranging from 15% among women with some high school, to 23% among the best educated women. Perhaps the most striking finding is the higher prevalence among women with birth experience (20-25%) compared with levels reported by women who have never given birth (8%). There is strong evidence to suggest that the majority of cases of anemia among women in Moldova are secondary to iron deficiency (UNICEF, 1997). Iron deficiency is primarily due to an unbalanced diet, with inadequate consumption of food with high content of iron, vitamins and micronutrients that stimulate iron absorption and a high intake of foods of non-animal origin which are low in iron content. Iron deficiency could be exacerbated during periods of rapid growth and during pregnancy, when a considerable amount of maternal iron is transferred to the fetus. When iron deficiency is highly prevalent in a population, pregnant women, who have a physiologic hemodilution and also higher iron requirements, are at greater risk of developing anemia than nonpregnant women. However, it is possible that the higher prevalence of anemia among women with pregnancy experience might also reflect differences in reporting, since pregnant women are more likely to find out about their anemia during prenatal care visits compared with women who have never been pregnant and may not have had any blood test. 247 Overall, 14% of women had been told by a doctor that they have or have had a urinary tract infection (UTI). The proportion of respondents reporting urinary infections varied directly with age ( from 10% among 15-24 to 18% among 34-44 year olds) and number of lifetime sexual partners (from 9% among virgins to 21% among women with four or more partners). It was 50% higher among women who have had at least one birth, compared with childless women. The prevalences of high blood pressure (HBP) and heart disease were directly correlated with age and number of living children (which is higher for older women) and did not vary by residence, education, and SES. Both conditions were less frequent among women in Transnistria and among those who never had sexual intercourse. HBP was 50% higher among employed women than among unemployed women. The overall prevalence of self-reported history of hepatitis B was 8%. Again, prevalence of this condition was lower among women in Transnistria compared with the rest of the country (3%). Reports of hepatitis B were directly correlated with the number of living children (from 6% among childless women to 10% among those with four or more children) and with the number of sexual partners (from 5% among women who never had intercourse to 13% among those with four or more lifetime partners). Given that less than one percent of women have ever been told that they have asthma or diabetes, no significant differences in prevalence were found among various subgroups. 248 CHAPTER XIV PHYSICAL AND SEXUAL ABUSE In recent years, physical and sexual abuse have come to be recognized as significant public health problems. Research shows that women of all ages and all socioeconomic and educational backgrounds experience these types of abuse. One goal of the MRHS was to document the prevalence of physical violence perpetrated by intimate partners (IPV) and lifetime exposure to sexual abuse among women of reproductive age in Moldova. Respondents were asked a series of questions related to past and present (within the past year) physical abuse or past sexual abuse. Violence by an intimate partner (i.e. domestic violence) was defined as verbal and physical abuse among all women with current or former spouses or non-marital partners. Verbal abuse includes insults, curses, and verbal threats and gestures with the intent of physical harm ("threaten to hit you or throw something at you"). Physical violence, further classified into moderate and severe violence (O'Campo P. et al., 1994), includes pushing, shoving, and slapping (moderate violence) and kicking, hitting with the fist or an object, being beaten up, and threats with a knife or other weapon (severe violence). Sexual abuse was defined as "being forced by a man to have sexual intercourse against [the woman's] will." The data presented here are estimates of abuse based on the information reported by respondents in face-to-face interviews. For both psychological and practical reasons, some women probably chose not to disclose their abuse history, despite assurances of maintaining confidentiality. Therefore, the estimates presented here are likely to underestimate the true population prevalence of physical and sexual abuse. 14.1 History of Verbal and Physical Abuse by a Partner or Ex-Partner In order to measure the lifetime prevalence of abuse by a current or former partner, women who ever had a partner were asked if they had ever been verbally or physically abused by a partner or ex-partner. The terms "partner" and "ex-partner" include a current or former spouse (legal or common-law) or other non-marital partner with whom the respondent may have cohabitated for any length of time. 249 250 Table 14.1.1 shows that 22% of women reported having been abused by a partner or ex- partner at some time in the past. About one in five women reported they were insulted by their partners and 13% said that they were threatened to be beaten or had thing thrown at them. One in seven women were pushed, shoved or slapped (14%). Between 9% and 3% suffered one form of severe violence (9% were kicked or hit with the fists or objects, 4% suffered severe beating and 3% were threaten with a knife or other weapon). To document some of the risk factors for abuse, the prevalence of ever having been abused by a partner or ex-partner was analyzed by selected characteristics of the respondents. Significant differences were found between rural and urban women, who reported lifetime prevalences of 27% and 17%, respectively (see also Figure 14.1.1). The differences were more pronounced in the prevalence of verbal abuse (26% vs. 17% for insults and 16% vs. 11% for threats of physical abuse) and in the history of moderate physical abuse (16% vs. 11%) and episodes of being hit with fists, objects or kicked (11% vs. 7%). The prevalence of severe beating or threats with weapons did not vary by residence. By region (data not shown), the highest prevalence of lifetime 251 abuse was reported by women living in the North and Central regions (27% and 24%, respectively), whereas the lowest prevalence was reported by respondents living in Transnistria (15%) and Chisinau (16%). The prevalence of physical abuse was directly correlated with age for every type of physical violence. However, age differences in reports of ever being abused are likely to be confounded by the length of exposure (older women having had a longer time exposed to the risk of abuse). For this reason, the association between age and IPV is better reflected in the study of present abuse (see Table 14.2.1). It is important, however, to note that, regardless the age, between 3%-4% of women reported having been beaten up at least once and of 2%-3% were threatened with weapons. When physical abuse by a partner or ex-partner was analyzed by the respondent's current marital status, women categorized as previously married or in union had significantly higher prevalence of past verbal and physical abuse, compared with never-married women and currently married (or in union) women (see Table 14.1.1 and Figure 14.1.2). Whereas 37% of those 252 previously married or in union reported past abuse, only 5% of never-married women and 22% of women currently married or in union reported having been abused. Although previously married women reported higher rates of any type of abuse, their higher prevalence of severe physical abuse is most disturbing. About one in four (26%) reported being hit with fists or kicked compared with only 3% of never-married women and 8% of currently married women. When compared with never-married and currently married/in union women, those previously married were fifteen times and five times, respectively, more likely to have been severely beaten and ten times and five times, respectively more likely to be threatened with a weapon. Although the survey did not asked if IPV contributed to a woman's decision to separate from her partner, these data suggest that women who were divorced and separated may have been exposed to more domestic abuse, contributing to their decision to split up with an abusive partner. As shown in Table 14.1.1. and Figure 14.1.3, the percentage of women reporting lifetime IPV was significantly higher among women with less than a post-secondary education, compared with women who attended technical college or university training. These results may be 253 confounded by a lower prevalence of past partner abuse among adolescents, who most likely have not yet completed high school. Thus, the prevalence of IPV among women with lower educational attainment is likely to be higher. Low educated (less than complete high school) women reported, on average, three times more physical abuse compared with the best educated women. For example, moderate abuse was reported by 19% vs 6%, being kicked or hit with fists or objects was reported by 13% vs. 4%, and being beat up by 5.5% vs. 1%. Thus, the gap between them and better educated women was narrower for verbal abuse and larger for moderate and severe physical abuse (the ratio of abuse among women with secondary education compared with university-trained women was about 2:1 for verbal abuse, 3:1 for moderate violence, and between 4 and 5:1 for severe violence. Similarly, the prevalence of IPV was inversely correlated with the partner's level of education. Women whose partners did not complete high school were, on average, three times more likely to be subjected to physical abuse than those with better educated partners. Women with at least one living child were significantly more likely (21% vs. 36%) than those with no children (11%) to have been abused. One in five women with one child, 22% of women with two children, and one in three women with three or more children (34%) reported having ever been abused by an intimate partner. The proportion of each type of abuse increased with parity. However, for severe beating and threats with weapons, women with one or more children had about the same risk for these types of violence (4% and 3%, respectively), about three and two times higher than childless women. These findings are particularly important because several researchers indicate that children who witness abuse between parents in their childhood are more prone to experience IPV as adults (Hotaling GT and Sugarman DB., 1986). Experience of lifetime domestic violence was inversely correlated with socio-economic status (SES). The highest rates were reported by women classified as having low SES, who were almost 2.5 times more likely to report IPV compared with women with high SES (32% vs. 13%). Again, the differences were wider for more severe types of abuse. Domestic violence was reported more often by Moldovan and Ukrainian women (23%) than among Russian women (14%)(data not shown). 14.2 Physical Abuse During the Past 12 Months by a Partner or Ex-Partner In order to obtain an idea of risk factors for current abuse, the prevalence of having been abused at some time during the past 12 months was analyzed by selected characteristics of the 254 respondents. Overall, 14% of all women interviewed reported having been physically abused by a partner or ex-partner during the last 12 months (Figure 14.2 and Table 14.2.1). Verbal abuse was reported by 13% (insults and curses) and 6% (threats of physical harm). Current moderate abuse was reported by 7% of women and current severe abuse by 4% (being "kicked, hit with fists or an object"), 2% (being "beat up"), and 1% ("threatened with a knife or other weapon"), respectively. As shown in Table 14.2.1, a significantly higher percentage of rural women (18%) reported abuse during the past 12 months compared with urban women (10%). As with lifetime abuse, current abuse was more frequently reported by women living in the North and Central regions (17% and 16%, respectively) compared with other regions (data not shown). Abuse during the past 12 months was highest among women aged 35-44 (17%) and the proportion reporting recent abuse was inversely related to age, decreasing to 14% among 25-34 year old women and 8% among 15-24 year olds. However, the age differentials are mostly the result of higher verbal abuse among older women, whereas other types of abuse are not significantly different by age. When current levels of domestic violence were analyzed by the woman's marital status it became clear that, although currently married women experienced higher levels of verbal abuse (15%), women previously married or in union were more likely to 255 256 report the two most serious types of violence—being beaten up (4%) and being threatened with a knife or other weapon (3%). Presumably, these violent episodes may have contributed to their marital dissolution. Prevalence of abuse within the past 12 months increased with parity. Whereas only 5% of women with no children reported recent abuse, 22% of those with three children and 32% of those with four or more children said they had been abused in the past year. Analysis of abuse during the last 12 months by education revealed that women with less than a high school degree were almost twice as likely to report recent abuse (19%) as were those with technical college (11%) and university education (8%). All types of violence were more prevalent among women with lower education and again the gap between them and better educated women was larger for moderate and severe physical abuse. Levels of recent abuse were inversely correlated with the partner's education level, from a maximum of 19 % among women whose partners did not complete secondary education to 8% among women with well-educated partners. Recent abuse was also more prevalent in low-SES households (21%) than in households with high SES (8%). Of the 14% of women who experienced IPV during the past year, 33% suffered physical injuries (Table 14.2.2). Furthermore, for 7% of these women the injuries were severe enough to require medical treatment and for 4% they required hospitalization. Reports of recent domestic- violence-associated-injuries were more prevalent among urban women (37%), divorced and separated women, women with one or more living children, low educated women and women with lower SES. The severity of these injuries and the need for medical treatment or hospitalization did not vary significantly with women's characteristics. Despite the seriousness of domestic violence (one-third of recently abused women abuse suffered injuries), women are reluctant to disclose their history of current abuse either because of fear or shame. Only about 30% of women who have been abused during the past year had talked to a family member or a friend about it (Table 14.2.3) and only 9% have talked to a medical care provider. The majority of cases of domestic violence were not reported to the police and only 2% have sought psychological counseling. Younger women and women who were divorced or separated were more likely to talk to a family member or a friend, whereas well-educated women were the least likely to do so. Discussions with a medical health provider were more common among previously married women who were victims of recent IPV, probably because of the severity of the abuse. These discussions were directly correlated with the number of living children—only 4% of childless women had talked to a medical health provider versus 11% of women with three or more children. Well-educated women were half as likely to talk to a health provider about their IVP experience as were lesser educated women. Police reports were the least common among young victims (15-24 years of age), childless women, women with post-secondary education and those with medium or high SES. Previously married women had the highest occurrence of police reports (18%), probably because of the severity of their abuse or the need for documentation of abuse; for legal separation. 257 258 259 Given that very few women reported disclosure of IPV to a medical health provider and only about one in five of those who had injuries sought medical help, the medical community has to adopt active measures to detect abused women and prevent future episodes. Health care providers have to be aware of the relatively high prevalence of IPV and the reluctance of victims to seek treatment (only 21% of those with injuries sought medical treatment) and should initiate inquiries about domestic violence experience during routine health visits. Such screening can effectively reduce the frequency and severity of intimate violence and can provide early interventions for domesticly abused victims. 14.3 Prevalence of Forced Sexual Intercourse It is difficult to know the frequency of forced sexual intercourse because, unlike other aggressions, the reporting rate to the police is very low. In countries with strong traditional values like Moldova, one reason may be the shame and fear of social stigma. Another reason, particularly when the perpetrator is an intimate partner, is the poor treatment received by victims from law enforcement agencies and the failure of the criminal justice system to punish aggressors. Thus, population-based surveys inquiring about physical violence, including rape, are regarded as an alternate methodology to obtain information about the prevalence of these events. To estimate the prevalence of forced sexual intercourse among women of reproductive age in Moldova, respondents were asked if they have " ever been forced by a man to have sexual intercourse against your will?" Respondents who answered affirmatively were considered sexually abused and were asked their relationship with the perpetrator(s) and the age at which did the first forced intercourse occurred. 260 261 Table 14.3 presents data on reported lifetime prevalence of forced sexual intercourse among women of reproductive age and correlates with individual characteristics. Overall, 4% of women of childbearing age reported they were subjected to forced sexual intercourse some time in their life. The prevalence of forced sexual intercourse was not significantly different among women with various characteristics, with the exception of previously married women (10%), who probably may have ended their marriages because of sexual abuse. Physical violence or threat of violence is often associated with sexual abuse. Women who reported a lifetime history of physical abuse by a partner or ex-partner (husband, boyfriend or date)also reported high prevalence of forced sexual intercourse (14%), whereas women who never experienced physical abuse by a partner were five times less likely to have ever been raped. Figure 14.3.1 presents the distribution of age at first abuse for women who had ever been forced to have intercourse. The survey found that 38% of these women had been raped for the first time prior to age 20 (7% when they were less than 16 years of age and 31% between ages 16-19). Most of those who were not abused before age 20 were abused before turning age 30 (43%). Very few women (10%) reported first forced sex at age 30 or over. Almost 9% did not remember or refused to answer at what age they had been raped. Researchers in the past decade have found that the vast majority of rapes are committed not by strangers but by someone known to the victim (Rape in America, 1992), often husbands or boyfriends. In MRHS, women who reported forced intercourse were asked about their relationships with the perpetrator(s) (Table 14.3 and Figure 14.3.2). Only one in five women who has ever been raped reported having been raped by a stranger. One in two women was forced to have sexual intercourse by her husband or ex-husband; 11% were raped by a boyfriend or ex-boyfriend; 14% were raped by a date or acquaintance. 262 CHAPTER XV KNOWLEDGE OF AIDS TRANSMISSION AND PREVENTION Of the estimated 4.5 million cases of acquired immunodeficiency syndrome (AIDS) in the world, only 4% have been reported in Europe (World Health Organization, 1995). However, according to WHO estimates, more than 500,000 people in Europe are infected with the human immunodeficiency vims (HIV), which causes AIDS. In 1995, there were 148,358 cases of AIDS reported in Europe (European Centre for the Epidemiological Monitoring of AIDS, 1995), of which only a few more than 5,000 cases were reported from Central and Eastern Europe. HIV infection is potentially a major health problem in Moldova, as it has proven to be in other European countries. As of August 1998, a total of 828 HIV-positive tests (W/BL test) in almost 4.5 million persons have been reported to the Moldovan Ministry of Health (since 1987 when the country introduced HIV testing). However, the positivity rate for HIV infections has dramatically increased in the past three years. From 1987 through 1995, there were only 40 HIV- positives for a rate of less than one per 100,000 population (0.87/100,000). In 1996 the number of infected individuals increased to 55, followed by 407 in 1997, and 326 more positive persons in the first eight months of 1998, for a total of 828 HIV positive persons, which corresponds to a positivity rate of 1 8.6 per 100,000 people (or 35.8/100,000 adults). It should be emphasized, however, that some infected individuals may have not been tested. Thus, the real rate may be much higher. Based on computer-generated models, the UNAIDS/WHO estimates that 2,500 adults in Moldova have HIV/AIDS, for a rate of about 110/100,000 adults (UNAIDS/WHO, 1998). Another change in the epidemiology of HIV infection in Moldova is the decrease in the prevalence of positive tests among foreigners (visitors) and the increase among Moldovans. Under the 1993 AIDS Prevention Law, HIV/AIDS testing is mandatory for all foreigners who want to spend more than three months in Moldova. Until 1995, 52% of the HIV-positive cases were reported among foreigners, all foreign students enrolled in Moldovan universities; since 1996, only 2% have been foreigners. The procedures of blood testing and case detection have changed in the last three years. Mandatory testing of some risk groups has been suspended. Of the 828 HIV infections officially reported, 792 were reported among Moldovans (36 additional cases were foreigners). Almost all of them (785 or 99%) have a known source of transmission. The great majority of cases were drug related (84%), followed by 15% associated with heterosexual transmission. Less than one percent were attributed to perinatal, post-transfusion or homosexual transmission. Most cases were between 20 and 39 years of age: 20-29 (60%) and 30-39 (21%). Almost three-fourths of infections were in men (73%). Of 792 infections with known 263 residence, there is a concentration of cases (699 cases or 88%) in the four municipalities: 330 (211/100,000) in Balti, 295 in Chisinau (39/100,000), 51 in Tiraspol (26/100,000), and 23 in Bender (17/100,000). The rate in the 40 raions ranges from 1/100,000 to 8/100,000, with the exception of Falesti and Ribnita where rates were 16/100,000. The Government recognized the seriousness of a potential AIDS epidemic and established an HIV testing laboratory in 1987; the National AIDS Center and the Republican Center for HIV/AIDS Prevention and Control were established in 1989. In 1995, the Government adopted the National Program for Prevention and Control of STD and HIV/AIDS, a multi-sector integrated program including NGOs, coordinated by the Republican Center for HIV/AIDS Prevention and Control. At the same time, as in other Eastern-European countries, Moldova has experienced an alarming increase in other sexually transmitted diseases (STDs), especially in primary and secondary syphilis. The reported syphilis rate (new cases) increased by almost 30 times between 1989 and 1996, from 7.1/100,000 population to 200.1/100,000 population (Republican Dermatovenerological Dispensary, 1998), reaching the second highest rate in Eastern Europe—after the rate reported by the Russia Federation of 250/100,000. In 1997 the rate dropped slightly to 188.4/100,000. These figures are based on the current national statistics and reflect only cases reported to the public health authorities; they may, in part, reflect better case ascertainment than in the past. In Moldova, reporting of HIV, syphilis, and gonorrhea is mandatory by law but these statistics reflect only patients who seek medical care and under-report those who avoid visiting a medical care provider and use self-treatment, those with asymptomatic STDs, and those with limited access to medical care. Furthermore, other STDs are not reported and the laboratory facilities are limited and often lack the ability to perform basic tests (e.g. chlamydia is diagnosed only in a few laboratories). Another critical issue in the epidemiology of STDs is the synergistic effect they may have on each other. From the beginning of the AIDS epidemic, it has become clear that HIV and other STDs could often be found in the same patients. Although these concurrent infections share common sexual risk factors, epidemiologic and biologic evidence shows that classic STDs can exacerbate HIV transmission, while HIV infection and related immunodeficiency may enhance susceptibility to other STDs (Laga et al., 1991, Wasserheit, 1992). In the past, primary prevention for STDs had been largely neglected, but with the emergence of HIV the public health community has given increased attention to the promotion of safer sexual behaviors through educational messages and increased condom availability. In the wake of the rapid increase in HIV positive cases in the recent years, both the national HIV/AIDS prevention program and the newly founded NGOs should make educating the general public about the threat of HIV infection and means of transmission a priority, along with promotion of safer sex and risk reduction practices. While increasing the level of knowledge about HIV and its transmission can successfully 264 prevent the spread of the disease among those at risk, efforts should also be made to raise awareness about other STDs. However, it is also critical that information does not convey needless threats to those having a very low risk of becoming infected. In order to effectively target these educational efforts, it is important to periodically examine STD knowledge among various population groups and define population subgroups in greater need of primary prevention messages, to identify factors that influence correct knowledge, and to better understand misconceptions surrounding HIV transmission. Worldwide, data on STD levels and behaviors related to the risk of STDs have demonstrated that a high priority should be given to educational efforts targeting adolescents and young adults. More information is needed to correct misperceptions and promote protective behaviors among youth. The 1997 MRHS included a module designed to assess the general level of HIV/AIDS awareness, the level and accuracy of knowledge about HIV transmission and prevention of HIV infection, and the self-perceived risk of HIV infection. In addition, respondents who have heard about HIV/AIDS were asked their main source of information about the disease and if they ever heard of other selected STDs. 15.1 Knowledge of AIDS and Other STDs Survey findings showed that awareness of HIV/AIDS is generally high in Moldova, but the ability to identify some other STDs is limited. When reproductive-age women were asked if they had ever heard of six specific STDs, virtually all said they were aware of AIDS (99%), syphilis (99%), and gonorrhea (89%), but fewer were aware of other common STDs (Table 15.1.1 and Figure 15.1). Overall, almost one in two women was aware of four common STDs (47%) whereas only 16% had heard of all six STDs. Respondents demonstrated moderate levels of awareness of trichomonas (78%) and low levels of knowledge about the names of several other diseases which are transmitted through sexual contact; only 24% of women recognized that genital warts are transmitted sexually and 22% of women had heard of genital herpes. The level of awareness about AIDS and syphilis was virtually universal across various population subgroups. However, for other STDs, the level of awareness varied substantially by some respondent characteristics. Generally, urban residence, older age, higher educational attainment, and sexual experience were associated with higher levels of awareness of specific STDs. Awareness was also higher in Chisinau and Transnistria. Awareness of gonorrhea, although very high (96%), dropped significantly among rural residents (82%), residents of the Central region (82%), young women (82%), never-married women (80%), women who did not complete high school (78%), and those who have never had intercourse (76%). Similarly, awareness of trichomonas was significantly lower within the same subgroups. For the least known STDs, such as genital herpes and genital warts, the awareness among these subgroups of women was 1.5 to 4 265 266 times lower compared with urban residents, older women, women with higher educational attainment, and those with a high number of lifetime sexual partners, respectively. The questionnaire did explore HIV/AIDS knowledge in greater depth. The findings underscored that simple awareness is not always an indication of knowing basic facts concerning AIDS. Awareness of AIDS, and by implication of other STDs, appears to be weakly associated with correct knowledge in some cases. For example, only 79% of women who had heard of AIDS (see Table 15.1.2) knew that HIV infection could be asymptomatic and a person could be infected without being sick. This finding is particularly alarming because the number of HIV-positive individuals living among a largely unsuspecting population is much higher than the number of individuals with AIDS symptoms and the consistent use of condoms remains low. Furthermore, although awareness of AIDS was almost universal among various subgroups, there are variations in the levels of knowledge that HIV/AIDS can be asymptomatic by sociodemographic characteristics. Only 73% of women in rural areas knew that HIV infection could be asymptomatic, compared with 86% of women in urban areas. AIDS knowledge was highest in Transnistria and South regions. Only 70% of women who did not finish high school knew that someone could be infected and have no symptoms, compared with 92% of women with a post-secondary education. Knowledge that the infection could be asymptomatic was slightly higher among women with two or more lifetime partners (84%) than among those with no sexual experience or one lifetime partner (77% and 78%, respectively). 267 268 15.2 Source of Information About HIV/AIDS As shown in Figure 15.2 and Table 15.2, the most important source of HIV information was announcements on television or radio; television broadcasts were mentioned by 53% of women, whereas radio programs were a source of information for only 3% of women. The proportion who mention seeing or hearing AIDS announcements as the first source of information was higher for women living in Transnistria region, those aged 25 or more, ever married, and with sexual experience. Also, women who knew that HIV infection could be asymptomatic were somewhat less likely to cite TV and radio as their most important source than women who did not have this knowledge (55% vs. 60%). The second most important source, mentioned by 20% of women, were magazines, brochures, and pamphlets. The proportion mentioning this source increased with age and education, and was higher among urban residents, sexually experienced respondents, and those with two or more lifetime sexual partners. Women who knew that HIV infection could be asymptomatic tended to get their information more often from written materials (magazines, brochures or pamphlets), compared with those who did not know HIV infection could be symptomless (22% vs. 14%). The proportion who mentioned school or a health-care worker as the most important source was negligible (10% and 7%, respectively). However, women who mentioned school as a source more often were aged 15-24 years (23%), never married (28%) or not sexually experienced (30%)—characteristics associated with younger age. These findings underscore the need for expanding school-based HIV/AIDS sex education and engaging the medical community in counseling and health education efforts. 269 270 15.3 Knowledge About HIV/AIDS Transmission The level of knowledge about AIDS transmission was assessed by asking respondents whether 12 statements about transmission were true or false. Respondents were classified as lacking knowledge if they reported that a specific activity was not associated with HIV transmission when in fact it was (answers "No") or they did not know if the means of transmission could cause infection (answers "Do not Know"). If respondents identified activities which in fact are not potential ways of transmission (answers "Yes"), they were classified as having "misinformation." For this latter group, however, those who answered "No" and "Do not Know" were grouped together as not having misinformation because not knowing about an unrecognized means of transmission was considered a correct answer. Overall, the level of knowledge of common modes of AIDS transmission was high, with 90% of women identifying correctly the four major means of transmission for HIV infection: sexual intercourse (heterosexual or homosexual), using non-sterile needles, and receiving blood transfusions. In addition, 8% of women gave only one wrong answer. Only 1% of women did not know whether any of these four means of transmission could spread the virus. Table 15.3.1 shows the percent of women with lack of knowledge about these four modes of transmission. Transmission through contaminated needles among drug users had been the major contributor to the AIDS spread in Moldova. The use of contaminated needles was highly publicized as a major public health concern and the national AIDS prevention programme concentrated its efforts to stop the spread of HIV through injections and to educate the general population about this risk. Overall, only 2% of women were not aware of this mode of transmission. Lack of knowledge of needle transmission was slightly higher among rural residents, those with less than complete secondary education, those with low socioeconomic status, and those with no sexual experience. However, none of these differences were significant. HIV infection from blood transfusions is another documented source of AIDS transmission. There is widespread knowledge among Moldovans that HIV infection could be transmitted through blood transfusions. Only 2% of women did not recognize this mode of transmission. Again, lack of knowledge was slightly higher among the subgroups previously mentioned. Homosexual intercourse is another important mode of spreading HIV infection, more prevalent in Western Europe and the U.S. In Moldova, less than 1% of HIV positive cases are found among homosexual/bisexual men. Knowledge of this risk was less prevalent than knowledge of other means of transmission; 8% of women thought that homosexual intercourse could not spread the AIDS virus or did not know what homosexual intercourse was. 271 272 The differences in knowledge were notable by place of residence. In rural areas and in the Central region, 12% of women and 14%, respectively, were not aware that homosexual intercourse could result in HIV transmission. Lack of knowledge about homosexual transmission was inversely correlated with age, education, socioeconomic level, and number of lifetime partners. Tables 15.3.2 shows the percent of women who have misinformation about HIV/AIDS transmission (agreed with means of transmission which cannot result in HIV spread) by background characteristics. Eight statements were used to assess misinformation about HIV/AIDS transmission and are listed in ascending order, from the least common misinformation to the most prevalent. Generally, the same groups that were the least likely to know valid means of HIV transmission (see Table 15.3.1) were also the most likely to have unfounded concerns. Overall, many women have some misperceptions about HIV/AIDS transmission, even though most correctly identified behaviors that could result in HIV spread. When the number of incorrect responses where totaled for each individual, only 1% of women answered all eight statements correctly, with most women giving three or more wrong answers (Figure 15.3). 273 274 Generally, shaking hands was rarely regarded as a route of HIV transmission (18% of women). In contrast, using public baths (douches and/or bathtubs) and sharing objects with a person with HIV infection were erroneously viewed by a sizable proportion as means of HIV transmission. Almost one in two women thought that using public baths carries the risk of contracting HIV or that sharing objects with HIV-infected persons could be a valid means of transmission. Rural residence, lower education, and lower SES were associated with higher levels of belief that HIV could be transmitted through casual contact. Women also hold a relatively high level of concern about HIV transmission through saliva (kissing) or insect bites. About one in two women thought HIV could be transmitted by kissing or mosquito bites. Again, rural residents and those with lower education and socioeconomic levels were more likely to have these misconceptions. Most women also believe that HIV transmission is common in nail parlors and barber shops (84%) and have misconceptions about donating blood (96%) and having surgery or dental treatments (94%). These concerns share a common misbelief that HIV is spread by sharp instruments or needles contaminated with blood from an infected person and reused without proper sterilization. Unwarranted concerns could have major public health consequences by deterring people from donating blood and from seeking medical care. Educational campaigns should emphasize that donating blood is safe and that infection-control procedures are in place in all medical facilities. Furthermore, the public should be informed that no AIDS cases have been attributed to these means of transmission. 15.4 Knowledge About HIV/AIDS Prevention Women who have heard about AIDS were also asked what a person could do to reduce the risk of getting AIDS. The percentages spontaneously mentioning means of preventing HIV transmission are shown in Table 15.4.1. If any of these eight means of prevention were not mentioned spontaneously, each one was individually probed by the interviewer. The probed answers were particularly useful in estimating the proportion of young people who have absolutely no awareness about ways to prevent HIV infection (Table 15.4.2 and Figure 15.4). Only 9% of women were not able to spontaneously mention any means to avoid HIV/AIDS transmission, whereas about 40% were able to name three or more means of prevention (not shown). The average number of methods of prevention reported spontaneously was 2.2 methods. Methods most frequently mentioned were using condoms (60%), using sterile needles (49%), having monogamous relationships (48%), and avoiding sex with prostitutes (23%) or with homosexual/ bisexual men (23%). Other behaviors were mentioned by 8% or fewer. 275 276 277 The lack of awareness about HIV testing as a means of detecting HIV carriers (an important element in AIDS prevention) is a special cause of concern since most HIV-infected individuals are asymptomatic; only 8% of women mentioned spontaneously that a possible way to avoid HIV infection is to ask a partner to be tested for HIV. Among other responses, some misconceptions about HIV prevention were notable; better hygiene, regular medical check-ups, and the use of oral contraceptives or local spermicides were considered valid means of prevention by a minority of women. Certain subgroups had more extensive knowledge about methods of preventing HIV transmission. Generally, knowledge about effective means of prevention was positively correlated with education and socioeconomic levels. Knowledge about the role of using clean needles in AIDS prevention was more prevalent among urban residents and women living in Chisinau. Knowledge about the merits of condom use in HIV prevention was more prevalent among ever-married women. 278 Awareness of HIV prevention improved substantially after probing. Virtually all women identified at least one behavior as an effective means of prevention (96%). Counting both spontaneous and probed answers, women were able to correctly identify an average of 5.9 means of preventing AIDS transmission. However, a minority of women remained unaware of effective protective behaviors (Table 15.4.2). Ten percent of women were not aware that you can protect against AIDS by avoiding unprotected sex with homosexual or bisexual men. Rural residents (14%), those living in the Central (14%) or North and South regions (13%), women with lower levels of education (12%) or low SES (17%), and those who never had sexual intercourse were the least knowledgeable. Nine percent were not aware that knowledge of one's HIV status through testing could contribute to preventive behaviors. Lack of knowledge about HIV testing was especially common among women residing in the Central region (12%) and women with less than secondary complete education (11%). Only 6% of women did not know that using condoms can protect against HIV infection. Rural residence, lower education and low SES, and having fewer than two lifetime partners were associated with lower levels of knowledge about the role of condoms in HIV prevention. Only 2% did not agree that commitment to a steady, monogamous relationship with an uninfected partner could protect against HIV infection. Only one percent did not know that the use of sterile needles could prevent HIV transmission and less than one percent of women were not aware that avoiding sex with prostitutes could lower the risk of contracting AIDS. Educational messages targeting youths should emphasize that the surest way to protect yourself against HIV sexual transmission (and against other STDs) is to abstain from sex or. if sexually active, to use condoms; messages should also convey that casual sexual relationships could potentially result in HIV or other STD transmission, but that using condoms every time protects against STDs. Efforts should also be made to increase awareness of the availability of testing for HIV antibodies and authorities should be prepared to provide counseling opportunities for those who seek elective tests. 15.5 Beliefs About Risk of HIV/AIDS Among Selected Groups and Self-Perceived Risk of HIV/AIDS Respondents were also asked about their perception of risk for persons in the selected groups shown in Table 15.5.1. Knowledge about groups at higher risk of contracting HIV is relevant because it may prevent individuals from engaging in risky sexual behaviors. Based on current scientific knowledge about HIV transmission, some health behaviors could place some individuals at higher risk of contracting HIV than others. Individuals practicing high risk 279 behaviors include those engaging in unprotected sexual intercourse with several partners (including men having sex with men), those who trade sex for money or drugs, and drug users who share intravenous needles (U.S. Department of Health and Human Services, 1994). Generally, these groups of people were correctly identified by most respondents as being at higher risk of HIV infection. An overwhelming majority (98%) believed that prostitutes have a high risk of getting infected with the AIDS virus. Drug users and homosexual men were also identified almost always as having high risks of AIDS (97% and 89%, respectively). The high risk attributed to sexually experienced unmarried men and women, regardless of their behaviors, contrasted with the low risk associated with married individuals. Two-thirds of women believe that unmarried people have a high risk of getting AIDS, whereas far fewer believed that married women and men have a high risk (7% and 9%, respectively). To assess their self-perceived vulnerability to HIV infection, respondents were also asked if they felt they had any risk of contracting AIDS and, if so, if they thought their risk was low or high. Their responses indicated that only a small percentage was seriously concerned about contracting AIDS (Table 15.5.2). 280 281 About one in four women said they had a low risk, 5% acknowledged some risk, and less than one percent believed they had a high risk of getting AIDS. The differences in perception about the risk of getting infected with the AIDS virus were rather small. Denial of HIV risk was slightly more common among respondents living in rural areas, those with lower education and low SES, and those with no sexual experience. Self-perception of some risk also varied by background characteristics. The percentage of women that thought they had low risk or some risk of contracting HIV was higher in urban area and in Chisinau, increased with education and SES, and was directly correlated with the number of lifetime partners. Whether because of denial or underestimation of personal risk, many women who perceived high levels of risk of HIV infection among similar population groups were not ready to accept that the same risks may extend to themselves. To illustrate this discrepancy, the perception of personal risk among sexually experienced women of all marital statuses was compared with their beliefs of HIV risk for other individuals with similar sexual and marital experience (Figure 12.5). Clearly, for all sexually experienced women there is a significant gap between their self-perceived high risk and their beliefs of high risk attributed to others. 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Although intensive quality-control efforts were made during the implementation of the 1997 MRHS to minimize this type of error, non-sampling errors are impossible to avoid altogether and difficult to evaluate statistically. Sampling error is a measure of the variability between an estimate and the true value of the population parameter intended to be estimated, which can be attributed to the fact that a sample rather than a complete enumeration was used to produce it. In other words, sampling error is the difference between the expected value for any variable measured in a survey and the value estimated by the survey. This sample is only one of the many probability samples that could have been selected from the female population aged 15-44 using the same sample design and projected sample size. Each of these samples would have yielded slightly different results from the actual sample selected. Because the statistics presented here are based on a sample, they may differ by chance variations from the statistics that would result if all women 15-44 years of age in Moldova would have been interviewed. Sampling error is usually measured in terms of the variance and standard error (square root of the variance) for a particular statistic (mean, proportion, or ratio). The standard error (SE) can be used to calculate confidence intervals (CI) of the estimates within which we can say with a given level of certainty that the true value of population parameter lies. For example, for any given statistic calculated from the survey sample, there is a 95 percent probability that the true value of that statistic will lie within a range of plus or minus two SE of the survey estimate. The chances are about 68 out of 100 (about two out of three) that a sample estimate would fall within one standard error of a statistic based on a complete count of the population. The estimated sampling errors for 95% confidence intervals (1.96 x SE) for selected proportions and sample sizes are shown in Table A.1. The estimates in Table A.1 can be used to estimate 95% confidence intervals for the estimated proportions shown for each sample size. 287 The sampling error estimates include an average design effect of 1.6, needed because the MRHS did not employ a simple random sample but included clusters of elements in the second stage of the sample selection. The selection of clusters is generally characterized by some homogeneity that tends to increase the variance of the sample. Thus, the variance in the sample for the MRHS is greater than a simple random sample would be due to the effect of clustering. The design effect represents the ratio of the two variance estimates: the variance of the complex design using clusters, divided by the variance of a simple random sample using the same sample size (Kish L., 288 1967). For more details regarding design effects for specific reproductive health variables, the reader is referred to the Le and Verma report, which studied demographic and health surveys in 48 countries (Le TN and Verma JK, 1997). The pattern of variation of design effects is shown to be consistent across countries and variables. Variation among surveys is high but less so among variables. Urban -rural and regional differentials in design effects are small, which can be attributed to the fact that similar sample designs and cluster sizes were used across domains within each country. At the country level, the overall design effect, averaged over all variables and countries, is about 1.5 (we used 1.6 in Table A.1 to be slightly more conservative). To obtain the 95% CI for proportions or sample sizes not shown in the table, one may interpolate. For example, for a sample size of 200 and a point estimate of 25% (midway between 0.20/0.80 and 0.30/0.70), the 95% CI would be plus or minus 7.5%; for a sample size of 300 (midway between 200 and 400) and an estimate of 20%, the 95% CI would be plus or minus 6.0%. Differences between estimates discussed in this report were found to be statistically significant at the five percent level using a two-tailed normal deviate test (p=0.05). This means that in repeated samples of the same type and size, a difference as large as the one observed would occur in only 5% of samples if there were, in fact, no differences between the proportion in the population. In this text, terms such as "greater," "less," "increase," or "decrease" indicate that the observed differences were statistically significant at the 0.05 level using a two-tailed deviate test. Statements using the phrase "the data suggest" indicate that the difference was significant at the 0.10 level but not the 0.05 level. Lack of comment in the text about any two statistics does not mean that the difference was tested and not found to be significant. The relative standard error of a statistic (also called "coefficient of variation") is the ratio of the standard error (SE) for that statistic to the value of the statistic. It is usually expressed as a percent of the estimate. Estimates with a relative standard error of 30% or more are generally viewed as unreliable by themselves, but they may be combined with other estimates to make comparisons of greater precision. For example, an estimate of 20% based on a sample size of only 50 observations yields a SE of 7% (one half the 95% confidence interval shown in Table A.1). The relative standard error would be 35% (the ratio of the SE of 7% to the estimate of 20%), too large for the estimate to be reliable. 289 290 APPENDIX B INSTITUTIONAL PARTICIPATION Moldovan Ministry of Health (MOH) -Valentina Melnik, MD, former Head of MCH/MOH -Eudochia Gaidau, MD, former Head of FP/RH -Petru Rosea, MD, former Head of Ob/Gyn/MOH Institute of Scientific Research of -Eugen Gladun, Prof, and Ob/Gyn Chair, Director Mother and Child Care (ISRMC) ISRMC (current Minister of Health) -Mihai Stratila, MD, Deputy Director -Valentin Friptu, MD, Chief of Research Dept. (Current Head of Ob/Gyn/MOH) -Valeria Jolea, MD Family Planning Association of Moldova -Veaceslav Moshin, MD, President FPAM (FPAM) (current Head of FP/RH, MOH) -Boris Gilca, Vice-President (current Director of DALILA Women's Health Center) - Manana Blaja, Executive Director - Iacob Anghel, Chief Accountant - Valentina Bodrug-Lungu, PhD State Department of Statistics -Eugenia Mihailov, General Director (SDS) -Anatol Craevschi, Director of Center for Vital Statistics (SDS/VS) -Vasile Pentelei, former Director of Census Division, SDS -Maria Strajescu, Head of Sampling Department USAID, EUR/DR/HR (Washington, D.C.) -Mary Ann Micka, MD, MPH, Director -Willa Pressman, Program Officer USAID (Chisinau) -Paul D. Morris, Former Program Coordinator -Vasile Filatov, Program Assistant 291 UNFPA (Bucharest) -Einar Sandved, Country Director for Moldova, UNFPA Representative, Romania -Rodica Furnica, Program Officer - Cornelia Iliescu, Financial Assistant - Katy J. Shroff, MB, BS, UNFPA/WHO Chief Technical Adviser, RH&FP UNDP (Moldova) -Ulrika Gustafson, Program Officer -Nadejda Chirica, Program Assistant -Elena Tiurina, Chief, Administrative Section UNICEF (Moldova) -Stefan Carlos Toma, Assistant Representative -Octavian Bivol, Project Officer CDC (Atlanta) -Leo Morris, PhD, MPH, Chief of Behavioral Epidemiology and Demographic Research Branch BEDRB/DRH -Florina Serbanescu, MD, MPH, BEDRB/DRH -Rebecca Amerson, MS, Computer Resources Section, Statistics and Computer Resources Branch (SCRB/DRH) 292 PERSONS INVOLVED IN THE 1997 MOLDOVAN REPRODUCTIVE HEALTH SURVEY OPERATION AND SUPERVISION National Director: • Mihai Stratila, MD, ISRMC Deputy Director: • Valentin Friptu, MD, ISRMC Field Coordinator: • Valeria Jolea, MD, ISRMC Secretary: • Ala Spirei Sampling Selection Supervisor: • Maria Strajescu Data Processing Supervisors: • Ludmila Olari, SDS/VS • Maria Usurelu, SDS/VS DRH/CDC Technical Assistance: • Fiorina Serbanescu, MD, MPH (BEDRB/DRH) • Leo Morris, PhD, MPH (BEDRB/DRH) • Rebecca Amerson, MS UNFPA Consultants: • Carmen Cruceanu, MD, Survey Operations Consultant • Doina Apostol, Data Processing Consultant 293 FIELD INVESTIGATORS Field Coordinator: Valeria Jolea Team Supervisors: Team No.l Elena Blindu Team No.2 Natalia Cotlearova Team No.3 Tatiana Buzdugan Team No.4 Nina Romanova Team No.5 Ludmila Zmucila Team No.l Team No.4 Eudochia Sirbu Rodica Izvac Maria Sirbu Ludmila Oclanscaia Eufrosinia Efremenco Natalia Cusnarova Viorica Pahoni Natalia Veverita Team No.2 Team No. 5 Galina Lupescu Maria Catavel Viorica Dodon Neli Godzina/ Galina Scerbacova Anastasia Palamari Aliona Rusu Violeta Malai Nina Dodon Team No.3 Lilia Popa Ludmila Chitic Rodica Tomulet Viorica Pancu 294 June 26, 1997 1997 MOLDOVA REPRODUCTIVE HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE ID NUMBER ____________ RAION____________________________________ CENSUS MAP _____________ URBAN/RURAL _ LOCALITY _________________________________ VILLAGE __________________________________ STREET ADDRESS __________________________ BUILDING/HOUSE NUMBER ________ APARTMENT NUMBER ______ VISIT RECORD Visit number 1 2 3 4 Day Month Day Month Day Month Day Month Date of visit ___________ ___________ __________ ___________ Result* --------- --------- -------- -------- Interviewer _____ _____ ____ _____ Supervisor --------- -------- -------- -------- * RESULT CODES 1 Completed Interview 2 No eligible woman (age 15-44) lives in the household 3 Nobody home 4 Selected Respondent not home 5 Household Refusal 6 Selected Respondent Refusal 7 Unocupied house 8 Respondent incompetent ____________ 9 Other _______________________________ 10 Incomplete interview 1. How many families live in this flat/house? families 295 2. How many people normally live in this flat/house? _ people 3. How many females between the ages of 15 and 44 live in this flat/house? _ females 4. For each of these women could you give me the following information (STARTING WITH THE OLDEST WOMAN TO THE YOUNGEST): Education No. 1 2 3 4 5 6 First Name --------------------- --------------------- --------------------- --------------------- --------------------- --------------------- Age --------- --------- --------- --------- --------- --------- Marital Status --------- --------- --------- --------- --------- --------- Level* ------- ------- ------- ------- ------- ------- Grade ------- ------- ------- ------- ------- ------- Marital Status Education: 1 Married 0 Never Attended School 2 Unregistered Marriage 1 Primary School 3 Separated 2 Secondary School 4 Divorced 3 Technical School 5 Widowed 4 University 6 Never Married 9 Unknown 9 Unknown GO TO THE RANDOMIZATION TABLE 296 IF NO ELIGIBLE WOMAN (AGE 15-44) LIVES IN THE HOUSEHOLD FINISH THE INTERVIEW (CODE=2) IF THE HOUSEHOLD CONTAINS AT LEAST ONE ELIGIBLE WOMAN, CONTINUE SELECTION OF INDIVIDUAL RESPONDENT USING RANDOMIZATION TABLE: LAST DIGIT OF QUESTIONNAIRE NUMBER NUMBER OF ELIGIBLE WOMEN LIVING IN THE HOUSEHOLD (SEE # IN Q 3) 0 1 2 3 4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 1 2 1 2 1 2 1 2 1 2 1 2 3 3 1 2 3 1 2 3 1 2 3 4 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 6 6 1 2 3 4 5 6 1 2 3 IF ONLY ONE WOMAN AGED 15-44 LIVES IN THIS HOUSEHOLD, WRITE ``I ´´IN Q5 5. RANK ORDER OF THE SELECTED RESPONDENT: __ IF YOU DO NOT SPEAK WITH THE SELECTED RESPONDENT OR IF SHE IS NOT AVAILABLE FOR AN INTERVIEW AT THAT TIME, WRITE DOWN HER FIRST NAME AND SCHEDULE ANOTHER VISIT (DATE AND TIME) FIRST NAME____________ DATE OF THE NEXT VISIT: _________________ TIME: ____________ 297 1997 MOLDOVA REPRODUCTIVE HEALTH SURVEY INDIVIDUAL QUESTIONNAIRE TIME STARTED:_______ : _____ ID NUMBER______________ -_ I. BACKGROUND CHARACTERISTICS 100. In what month and year were you born? MONTH _______ 99 DON'T KNOW YEAR 19 _____ 101. How old are you (at last birthday)? ________ YEARS OLD 99 DON'T KNOW MAKE SURE THAT AGE AND DATE OF BIRTH CORRESPOND 102. What is the highest grade in school you successfully completed, not counting the current grade you are in? CLASSES 000. NEVER ATTENDED 1. GENERAL SCHOOL/HIGH SCHOOL. 1 2 3 4 5 6 7 8 9 10 11 12 99 2. PROFESSIONAL SCHOOL . 1 2 3 99 3. TECHNICAL SCHOOL/POST HS . 1 2 3 4 5+ 99 4. UNIVERSITY/FACULTY . 1 2 3 4 5+ 99 5. POST UNIVERSITY/GRADUATE STUDIES. 1 2 3 4 5+ 99 999. DON'T REMEMBER/DON'T KNOW 104. Do you currently work outside of the home (at least 20 hours per week)? 1 YES—> GO TO Q106 2 YES, BUT ON MATERNITY/PREGNANCY LEAVE—> GO TO Q106 3 NO 298 105. What is the main reason that you are not working at this time? 1. ATTENDING SCHOOL 2. VACATION 3. LOOKING FOR WORK 4. I,AID OFF 5. DOES NOT NEED/WANT/LIKE TO WORK 6. MEDICAL LEAVE 7. MATERNITY LEAVE 8. INABILITY TO FIND/AFFORD CHILD CARE 9. HOMFMAKER 10. PERMANENT DISABILITY 20. OTHER (SPECIFY)-------------------------------- 106. What is it that you most enjoy reading? (READ 1-7): YES NO 1. Newspapers and Magazines I 2 2. Technical Books 1 2 3. Classical Literature I 2 4. Recreational Literature I 2 5. Novels on Love and Adventure Stories 1 2 6. Thrillers or Sci-Fi 1 2 7. Bible/Religious Books 1 2 8. Other (Please Specify)_ 1 2 107. Do you listen to the radio daily? 1. YES 2. NO 108. What stations do you most often listen to?(CIRCLE ONE FOR ALL MENTIONED, DO NOT READ LIST) MENTIONED NOT MENTIONED RADIO MOLDOVA. 1 2 RADIO ROMANIA . 1 2 RADIO RUSIA. . 1 2 RADIO UCRAINA . 1 2 RADIO NOVA. 1 2 RADIO PLUS . 1 2 POLIDISC . 1 2 ELDORADIO . 1 2 UNDA LIBERA. I 2 OTHER---------------------- . 1 2 109. Within the past 6 months, have you lisened to any program or ad on radio about family planning? 1. YES 2. NO 110. More or less how many hours a day do you spend watching television? Hours a day-------------- 00 NEVER 66. NOT EVERY DAY 77. DOES NOT HAVE TV 88. DON'T KNOW 299 111. What chanenels do you most often watch? (CIRCLE ONE FOR ALL MENTIONED, DO NOT READ LIST) MENTIONED NOT MENTIONED TV MOLDOVA (TVM). 1 2 TV ROMANIA (TVR1/PROTV) . 1 2 TV MOSCOVA (OR1/XXI/ACT) . 1 2 TV UCRAINA . 1 2 TV CATALAN . 1 2 TV PREDNISTROVIA (1PR) . 1 2 CNN/BBC . 1 2 OTHER __________ . 1 2 112. Within the past 6 months, have you seen any program or ad on television about family planning? l. YES 2. NO 113. Do you think information about contraception should be broadcast on radio or television? l. YES 2. NO 8. NOT SURE 114. Are you currently married, not married but living with someone, separated, divorced, widowed, or have you never been married ? 1 MARRIED--> GO TO Ql16 2 NOT MARRIED BUT LIVING WITH A PARTNER --> GO TO Q1I6 3 SEPARATED \->GO TO Q116 4 DIVORCED / 5 WIDOWED / 6 NEVER MARRIED 115. Have you ever lived with a boyfriend or partner? 1. YES 2. NO—>GO TO BOX l-II PAGE 4 116. How many times have you been married or lived with a man? __ TIMES 117. In what month and year did you begin living with your (first) husband/partner? MONTH _____ YEAR 19 ____ 98 DON'T KNOW 118. When you first got married did you wish to have any children? 1 YES 2 NO ---- >GO TO BOX 1-1 3 NOT SURE - >GO TO BOX 1-1 119. How many children did you wish to have when you first got married? 1. 1 6. 3-4 2. 1-2 7. 4 OR MORE 3. 2 8. AS MANY AS GOD GIVES 4. 2-3 20. OTHER: ____________ 5. 3 88. NOT SURE/DON``1``REMEMBER BOX 1-1 IFQ114=3,4,5, OR 6 GO TO BOX1-II 300 120. What was the highest grade in school that your husband/partner completed? CLASSES 000. NEVER ATTENDED 1. GENERAL SCHOOL/HIGH SCHOOL. 1 2 3 4 5 6 7 8 9 10 11 12 99 2. PROFESSIONAL SCHOOL . 1 2 3 99 3. TECHNICAL SCHOOL/POST HS . 1 2 3 4 5+ 99 4. UNIVERSITY/FACULTY . 1 2 3 4 5+ 99 5. POST UNIVERSITY/GRADUATE STUDIES . 1 2 3 4 5+ 99 999. DON'T REMEMBER/ DON'T KNOW 121. How old is your husband or partner? AGE _____(SPECIFY AGE AT LAST BIRTHDAY) 88 DO NOT KNOW BOX l-II IF RESPONDENT IS 15-24 YEARS OF AGE CONTINUE; IF SHE IS 25-44 YEARS OF AGE GO TO Q200 122. Is your father still alive? 1.YES 2. NO —>GO TO Q124 3.1 NEVER KNEW HIM —> GO TO Q126 8. DON'T KNOW —>GO TO Q124 123. Do you live with him? 1. YES —>GO TO Q125 2. NO 124. Until what age did you live with your father? AGE ____ 00 NEVER 88 DON'T REMEMBER IFQ124 < 10 GO TO Q126 125. Were you close to your father when you were between 10 and 15 years of age? 1. VERY CLOSE 2. CLOSE 3. NOT CLOSE 4. DID NOT LIVE WITH HIM BETWEEN 10-15 8. DON'T REMEMBER 301 126. Is your mother still alive? 1. YES 2. NO —>GO TO Q128 3.1 NEVER KNEW HER —>GO TO Q200 8. DON'T KNOW -------------->GO TO Q128 127. Do you live with her? l. YES —>GO TO Q129 2. NO 128. Until what age did you live with your mother? AGE ____ 00 NEVER 88 DON'T REMEMBER IFQ128 < 10 GO TO Q200; OTHERWISE CONTINUE 129. Were you close to your mother when you were between 10 and 15 years of age? 1. VERY CLOSE 2. CLOSE 3. NOT CLOSE 4. DID NOT LIVE WITH HER BETWEEN 10-15 8. DON'T REMEMBER 130. What was the highest level of education that your mother finished in school or university? CLASSES 000 NEVER ATTENDED 1. GENERAL SCHOOL/HIGH SCHOOL . 1 2 3 4 5 6 7 8 9 10 11 12 99 2. PROFESSIONAL SCHOOL . 1 2 3 99 3. TECHNICAL SCHOOL/POST HS . 1 2 3 4 5+ 99 4. UNIVERSITY/FACULTY . 1 2 3 4 5+ 99 5. POST UNIVERSITY/GRADUATE STUDIES . 1 2 3 4 5+ 99 999. DON``1`` REMEMBER/ DON'T KNOW 302 II. SEX EDUCATION The next set of questions are about sex education. 201. Do you think schools should teach courses about reproductive biology, contraception, and prevention of sexually transmitted diseases? 1. YES 2 NO -> GO TO 203 8. DK 9. NR -->GO TO 203 202. At what year of age should they begin to teach about? (READ A-C) A. How pregnancy occurs? ------------- 77. Should not be taught in school. B. Contraception? ------------- 88. DK C. STD's ------------- 99. NR SKIP TO BOX2-I 203. Now I want to read some reasons for which one may oppose sex education in school. Please tell me if you agree or don't agree. (READ A-C) AGREE DISAGREE DK NR A. Sex education will give adolescents the Idea to begin sex earlier. 1 2 8 9 B. Sex education should be taught only in the house 1 2 8 9 C. Sex education goes against my religious beliefs 1 2 8 9 BOX2-I IF RESPONDENT IS 15-24 YEARS OF AGE CONTINUE; IF SHE IS 25-44 YEARS GO TO SECTION III 204. Before you were 18 years old, did you ever talk with a parent about.(READ A-E) YES NO PR NR A. Menstrual Cycle? . 1 2 8 9 B. How pregnancy occurs? . 1 2 8 9 C. Methods of birth control? . 1 2 8 9 D. Sexually transmitted diseases? . 1 2 8 9 E. HIV/AIDS? . 1 2 8 9 303 READ EACH QUESTION 205-207 FROM THE TABLE FOR EACH TOPIC OF SEX EDUCATION: TOPIC 205. Before you were 18 years old, have you ever been taught at school about.? (READ A-G) 206. How old were you when you first were taught at school about.? 207. Who taught you at school about.? A. Menstrual Cycle 1 YES ->GO TO Q206 2 NO --> GO TO Q205B 8 DK --> GO TO Q205B 9 NR --> GO TO Q205B -------- 1 TEACHER 2 DOCTOR/NURSE 3 VOLUNTEER 7 OTHER 8 DON'T REMEMBER B. Female Reproductive System 1 YES --> GO TO Q206 2 NO --> GO TO Q205C 8 DR --> GO TO Q205C 9 NR ->GO TO Q205C --------- 1 TEACHER 2 DOCTOR/NURSE 3 VOLUNTEER 7 OTHER 8 DON'T REMEMBER C. Male Reproductive System 1 YES -> GO TO Q206 2 NO -> GO TO Q205D 8 DR -> GO TO Q205D 9 NR ~> GO TO Q205D --------- 1 TEACHER 2 DOCTOR/NURSE 3 VOLUNTEER 7 OTHER 8 DON'T REMEMBER D. How Pregnancy Occurs 1 YES --> GO TO Q206 2 NO -> GO TO Q205E 8 DR -> GO TO Q205E 9 NR -> GO TO Q205E --------- 1 TEACHER 2 DOCTOR/NURSE 3 VOLUNTEER 7 OTHER 8 DON'T REMEMBER E. Contraceptive Methods 1 YES --> GO TO Q206 2 NO ~> GO TO Q205F 8 DR ~> GO TO Q205F 9 NR ~> GOTOQ205F --------- 1 TEACHER 2 DOCTOR/NURSE 3 VOLUNTEER 7 OTHER 8 DON'T REMEMBER F. Sexually Transmitted Diseases 1 YES --> GO TO Q206 2 NO -> GO TOQ205G 8 DR -> GO TO Q205G 9 NR -> GO TO Q205G --------- 1 TEACHER 2 DOCTOR/NURSE 3 VOLUNTEER 7 OTHER 8 DON'T REMEMBER G. HIV/AIDS 1 YES --> GO TO Q206 2 NO -> GO TO Q208 8 DR ~> GO TO Q208 9 NR ~> GO TO Q208 --------- 1 TEACHER 2 DOCTOR/ NURSE 3 VOLUNTEER 7 OTHER 8 DON'T REMEMBER 208. Have you ever attended a lesson, course or lecture on sex education outside of school? 1. YES 2. NO —> GO TO SECTION III 8. DON'T REMEMBER—> GO TO SECTION III 209. Where did you get this lesson, course, or lecture on sex education? 1. POLICLINIC 2. WOMEN'S CONSULTATION CENTER 3. HOSPITAL 4. COMMUNITY CENTER 20. OTHER _______________ 88. DON'T REMEMBER 304 III. FERTILITY/PREGNANCY 300. Are you currently pregnant? 1 YES 2 NO—>GO TO Q305 3 NOT SURE—>GO TO Q305 301. How many months pregnant are you now? _______ MONTHS 302. Just before you get pregnant, did you want to get pregnant then, did you want to get pregnant later, or did you not want to get pregnant then or any time in the future? 1. WANTED TO GET PREGNANT THEN 2. WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 303. Is this your first pregnancy? 1 YES 2 NO---------- >GO TO Q307 3 NOT SURE 304. Have you ever had a stillbirth, ectopic pregnancy, miscarriage, or an induced abortion? 1 YES---- >GO TO PREGNANCY TABLE 2 NO ----- >GO TO MODULE IV 305. Have you ever been pregnant? 1 YES--------- >GO TO Q307 2 NO 3 NOT SURE 4 NEVER HAD SEX -> GO TO MODULE IV 306. Have you ever had a stillbirth, ectopic pregnancy, miscarriage, or an induced abortion? 1 YES ---- >GO TO PREGNANCY TABLE 2 NO ----->GO TO MODULE IV 307. Have you ever had any live-born children? 1. YES 2 NO >GO TO PREGNANCY TABLE 308. How many living children do you have, including those who do not live with you? ____________ CHILDREN 309. Have you ever had a child born alive who later died or died right after birth? 1. YES 2. NO -> GO TO PREGNANCY TABLE 310. How many children died? ____ CHILDREN 310A. So altogether you had a total of ___________(Q308+Q310) live births? 1. YES 2 NO------>CHECK Q308 AND Q310 AND MAKE CHANGES IF NECESSARY 3 305 PREGNANCY HISTORY Now I would like to talk to you about all your pregnancies (not counting the current one). Please, make sure you include all pregnancies, it doesn't matter when they happened or how they ended, whether in a live birth, an abortion, a miscarriage, or a stillbirth. Starting with your most recent pregnancy, please give me the following information: 316 311 312 313 314 315 IF Q313B < 92 — >GO TO NEXT PREGNANCY How did that pregnancy end? When did that pregnancy end? (month & year) How many weeks or months had you been pregnant when that pregnancy ended? Was the baby a boy or a girl? Just before you get pregnant, did you want to get pregnant then, did yo want to get pregnant later, or did you not want to get pregnant then or any time in the future? l l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A _____ MONTH B.------ YEAR 98.DK 99.NR 1____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 2 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A _____ MONTH B.------ YEAR 98.DK 99.NR 1____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 3 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A _____ MONTH B.------ YEAR 98.DK 99.NR 1____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 4 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A _____ MONTH B.------ YEAR 98.DK 99.NR 1____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 5 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A _____ MONTH B.------ YEAR 98.DK 99.NR 1____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 306 316 311 312 313 314 315 IF Q313B < 92 — >GO TO NEXT PREGNANCY 6 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 7 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 8 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 9 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 10 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 11 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 307 316 311 312 313 314 315 IF Q313B < 92 — >GO TO NEXT PREGNANCY 12 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 13 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 14 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 15 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 16 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 17 l. LIVE BIRTH (SINGLE) 2. MULTIPLE LIVE BIRTH 3. MULTIPLE (LB WITH SB) 4. STILLBIRTI I (SINGLE) 5. MULTIPLE STILLBIRTH 6. MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 308 316 311 312 313 314 315 IF Q313B < 92 —>GO TO NEXT I'REGNANCY 18 1.LIVE BIRTH (SINGLE) 2.MULTIPLE LIVE BIRTH 3.MULTIPLE (LB WITH SB) 4.STILLBIRTH (SINGLE) 5.MULTIPLE STILLBIRTH 6.MISCARRIAGE 7.INDUCED ABORTION 8. MINIABORTION 9.ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 19 1.LIVE BIRTH (SINGLE) 2.MULTIPLE LIVE BIRTH 3.MULTIPLE (LB WITH SB) 4.STILLBIRTH (SINGLE) 5.MULTIPLE STILLBIRTH 6.MISCARRIAGE 7 INDUCED ABORTION 8. MINIABORTION 9. ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 20 1.LIVE BIRTH (SINGLE) 2.MULTIPLE LIVE BIRTH 3.MULTIPLE (LB WITH SB) 4 STILLBIRTH (SINGLE) 5 MULTIPLE STILLBIRTH 6.MISCARRIAGE 7.INDUCED ABORTION 8. MINIABORTION 9 ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 8. NOT SURE 21 1.LIVE BIRTH (SINGLE) 2.MULTIPI.E LIVE BIRTH 3 MULTIPLE (LB WITH SB) 4.STILLBIRTH (SINGLE) 5.MULTIPLE STILLBIRTH 6.MISCARRIAGE 7.INDUCED ABORTION 8. MINIABORTION 9.ECTOPIC PREGNANCY A ____ MONTH B.------ YEAR 98.DK 99.NR 1 ____ WEEKS OR 2 ------ MONTHS 888.DK 998.NR IFQ312>5GOTOQ316 I. BOY 2. GIRL 3. BOTH 1. WANTED TO GET PREGNANT THEN 2.WANTED TO GET PREGNANT LATER 3. DID NOT WANT THE PREGNANCY THEN OR ANY TIME IN THE FUTURE 9. NOT SURE GO TO BOX III-l UNDER THE TABLE BOX3-I >- THE FOLLOWING QUESTIONS ARE ONLY FOR PREGNANCIES ENDED BETWEEN 1992-1997. IF RESPONDENT HAD AT LEAST A LIVEBIRTH, STILLBIRTH, INDUCED ABORTION, OR MINIABORTION (Q312=1-5, 7, 8) ENDED BETWEEN 1992-1997 THEN CONTINUE WITH 0317 ON THE NEXT PAGE; >- IF SHE HAD ONLY MISSCARIAGE(S) OR ECTOPIC PREGNANCY(IES ) (Q312=6,9), GO TO Q365 PAGE 16; >- IF SHE DID NOT HAVE ANY PREGNANCY IN 1992-1997 (CHECK Q313B), GO TO MODULE IV, PAGE 17. 309 s Text Box IF Q313B < 92 — >GO TO NEXT PREGNANCY 317. HOW MANY INDUCED ABORTIONS AND/OR MINIABORTIONS DID THE RESPONDENT HAVE BETWEEN JANUARY 1992 AND THE PRESENT (SEE PAGE 9) 1. INDUCED ABORTIONS _____ 2. MINIABORTIONS__________(IF NO INDUCED ABORTION OR MINIABORTION, GO TO Q331) 318. COPY LINE #. FROM Q311 LAST ABORTION ------- NEXT TO LAST ABORTION ------- SECOND TO LAST A B. ------- THIRD TO LAST AB. ------- 319. ABORTION TYPE (SEE Q312) 1 INDUCED ABORTION 2 MINIABORTION 1. INDUCED ABORTION 2 MINIABORTION 1. INDUCED ABORTION 2. MINIABORTION 1. INDUCED ABORTION 2. MINIABORTION 320. What was the principal reason that you decided to have this abortion? 1. PREGNANCY WAS LIFE OR HEALTH THREATENING 2. RISK OF BIRTH DEFECTS 3. SOCIOECONOMIC REASONS 4. RESPONDENT DID NOT WANT (ANY) CHILDREN 5. PARTNER DID NOT WANT (ANY) CHILDREN 6 DID NOT HAVE A PARTNER 7. OTHER ----------------------- 1. PREGNANCY WAS LIFE OR HEALTH THREATENING 2. RISK OF BIRTH DEFECTS 3. SOCIOECONOMIC REASONS 4. RESPONDENT DID NOT WANT (ANY) CHILDREN 5. PARTNER DID NOT WANT (ANY) CHILDREN 6 DID NOT HAVE A PARTNER 7. OTHER ----------------------- 1. PREGNANCY WAS LIFE OR HEALTH THREATENING 2. RISK OF BIRTH DEFECTS 3. SOCIOECONOMIC REASONS 4. RESPONDENT DID NOT WANT (ANY) CHILDREN 5. PARTNER DID NOT WANT (ANY) CHILDREN 6 DID NOT HAVE A PARTNER 7. OTHER ----------------------- 1. PREGNANCY WAS LIFE OR HEALTH THREATENING 2. RISK OF BIRTH DEFECTS 3. SOCIOECONOMIC REASONS 4. RESPONDENT DID NOT WANT (ANY) CHILDREN 5. PARTNER DID NOT WANT (ANY) CHILDREN 6 DID NOT HAVE A PARTNER 7. OTHER ----------------------- 321. Where was that abortion performed? 1. HOSPITAL (GYN WARD) 2. MATERNITY 3. OUTSIDE HOSPITAL 7. OTHER-------------------------- 1. HOSPITAL (GYN WARD) 2. MATERNITY 3. OUTSIDE HOSPITAL 7. OTHER------------------------- 1. HOSPITAL (GYN WARD) 2. MATERNITY 3. OUTSIDE HOSPITAL 7. OTHER------------------------ 1. HOSPITAL (GYN WARD) 2. MATERNITY 3. OUTSIDE HOSPITAL 7. OTHER------------------------- 322. How much did you payed for that abortion? ---------- LEI 000 NO CHARGE 7 777 GIFTS 888 DK ---------- LEI 000 NO CHARGE 7 777 GIFTS 888 DK ---------- LEI 000 NO CHARGE 7 777 GIFTS 888 DK ---------- LEI 000 NO CHARGE 7 777 GIFTS 888 DK 323.Soon after this abortion did you have any complications that required treatment7 1. YES 2 NO ------ > GO TO Q325 1 YES 2 NO ---- >GO TO Q325 1. YES 2 NO ------->GO TO Q32S 1. YES 2 NO ------ GO TO Q325 324. What was the most important complication? 1. PERFORATION 2. HEMORRHAGE 3. FEVER 4. DISCHARGE, INFECTION 5. PELVIC PAIN 7. OTHER------------------------- 1. PERFORATION 2. HEMORRHAGE 3. FEVER 4. DISCHARGE, INFECTION 5. PELVIC PAIN 7. OTHER------------------------- 1. PERFORATION 2. HEMORRHAGE 3. FEVER 4. DISCHARGE, INFECTION 5. PELVIC PAIN 7. OTHER-------------------------- 1. PERFORATION 2. HEMORRHAGE 3. FEVER 4. DISCHARGE, INFECTION 5. PELVIC PAIN 7. OTHER------------------------- 325. How many nights did you spend in the hospital after that abortion (+re-admisions during the first month) ? _____ NIGHTS 88 DK _____ NIGHTS 88 DK _____ NIGHTS 88 DK _____ NIGHTS 88 DK 326. Did you have any related health problems more than 6 months later? 1. YES 2. NO ---- >Q328 3. NOT YET 6 MTH.—>Q328 8. DON'T REMEMBER—>Q328 1 YES 2. NO ---- >Q328 3. NOT YET 6 MTH.—>NEXT IA 8, DON'T REMEMBER->NEXT IA 1. YES 2. NO ----->Q328 3. NOT YET 6 MTH.—>NEXT IA 8. DON`T REMEMBER->NEXT IA 1. YES 2. NO----->Q328 3. NOT YET 6 MTH.—>Q331 8. DON'T REMEMBER—>Q331 327.What was the most important health problem? 1. PELVIC PAIN 2. STERILITY 3. INFECTION 4. LACK OF MENSES 5. IRREGULAR BLEEDINGS 6. DYSMENORREA 7. OTHER 1. PELVIC PAIN 2. STERILITY 3. INFECTION 4 LACK OF MENSES 5. IRREGULAR BLEEDINGS 6 DYSMENORREA 7 OTHER 1. PELVIC PAIN 2. STERILITY 3 INFECTION 4. LACK OF MENSES 5. IRREGULAR BLEEDINGS 6. DYSMENORREA 7. OTHER 1 PIT.VIC PAIN 2 STERILITY 1 INFECTION 4. LACK OF MENSES 5. IRREGULAR BLEEDINGS 6. DYSMENORREA 7 OTHER 328. Either before or after the most recent abortion, did a doctor talk to you about contraception? 1. YES 2. NO 8. DON'T REMEMBER 330. After the most recent abortion, did you receive a method of contraception or prescription? 1. GOT A METHOD \ 2 GOT PRESCRIPTION \ 3. NO \GO TO 8. DON'T REMEMBER /NEXT A ABORTION 310 331. HOW MANY BIRTHS HAS THE RESPONDENT HAD BETWEEN JANUARY 1992 AND PRESENT (SEE PG. 9) 1. LIVE BIRTHS ___ 2. STILLBIRTHS ___ (IF NO LIVEBIRTH OR STILLBIRTH GO TO Q365 PAGE 16) 332. COPY LINE #. FROM Q311 LAST BIRTH ------- NEXT TO LAST BIRTH ------- SECOND TO LAST BIRTH ------- 333. Did you smoke before you became pregnant? 1. YES 2 NO—>GO TO Q335 8. DON'T REMEMBER->GO TO Q335 1. YES 2 NO—>GO TO Q335 8. DON'T REMEMBER->GO TO Q335 1. YES 2 NO—>GO TO Q335 8. DON'T REMEMBER->GO TO Q335 334. Did you continue to smoke during that pg. ? 1 YES 2 NO 1 YES 2 NO 1. YES 2. NO 335. How many times per week did you drink alcoholic beverages during that pgnancy? 1. 4 TIMES OR MORE 2. 1-3 TIMES 3. LESS THAN ONCE PER WEEK 4. NEVER 1. 4 TIMES OR MORE 2. 1-3 TIMES 3. LESS THAN ONCE PER WEEK 4. NEVER 1. 4 TIMES OR MORE 2. 1-3 TIMES 3. LESS THAN ONCE PER WEEK 4. NEVER 336. During that pregnancy, did you have any prenatal care visits? 1. YES 2 NO—>GO TO Q345 8. DON'T REMEMBER->GO TO Q345 1. YES 2 NO—>GO TO Q345 8. DON'T REMEMBER-> GO TO Q345 1. YES 2 NO—>GO TO Q345 8. DON'T REMEMBER->GO TO Q345 337 How many months pregnant were you at the time of your first prenatal care visit? MTH 88. DK 9 98. REF MTH 88. DK 9 98. REF MTH 88. DK 9 98. REF 338. 1 low many prenatal visits did you have during that pregnancy? VISITS 88. DK 98. REF VISITS 88. DK 98. REF VISITS 88 DK 98. REF 339. Where did you have most of the prenatal care visits? 1. PRIMARY HEALTH CARE UNIT 2. MEDICAL AMBULATORIUM 3. RAIONAL CONSULTATION FOR WOMEN 4. CITY CONSULTATION FOR WOMEN 5. REPUBLICAN POLYCLINIC 6. HOME 7 OTHER------------------- 1. PRIMARY HEALTH CARE UNIT 2. MEDICAL AMBULATORIUM 3. RAIONAL CONSULTATION FOR WOMEN 4. CITY CONSULTATION FOR WOMEN 5. REPUBLICAN POLYCLINIC 6. HOME 7 OTHER------------------- 1. PRIMARY HEALTH CARE UNIT 2. MEDICAL AMBULATORIUM 3. RAIONAL CONSULTATION FOR WOMEN 4. CITY CONSULTATION FOR WOMEN 5. REPUBLICAN POLYCLINIC 6. HOME 7 OTHER------------------- 340. During those visits, did you receive any information about (READ A-H): YES NO A. Nutrition 1 2 B. Smoking during Pregnancy I 2 C. Drinking Alcohol during Pg. 1 2 D. Breastfeeding ] 2 E. Delivery 1 2 F. Contraception I 2 G. Warning Signs of Pg. Complic. 1 2 H. Postnatal Care 1 2 YES NO A. Nutrition 1 2 B. Smoking during Pregnancy I 2 C. Drinking Alcohol during Pg. 1 2 D. Breastfeeding ] 2 E. Delivery 1 2 F. Contraception I 2 G. Warning Signs of Pg. Complic. 1 2 H. Postnatal Care 1 2 YES NO A. Nutrition 1 2 B. Smoking during Pregnancy I 2 C. Drinking Alcohol during Pg. 1 2 D. Breastfeeding ] 2 E. Delivery 1 2 F. Contraception I 2 G. Warning Signs of Pg. Complic. 1 2 H. Postnatal Care 1 2 341. During those visits, did you have your blood pressure measured? 1. YES 2 NO—>GO Q343 8 DON'T REMEMBER->GO TO Q343 1. YES 2 NO—>GO Q343 8 DON'T REMEMBER->GO TO Q343 1. YES 2 NO—>GO Q343 8 DON'T REMEMBER->GO TO Q343 342. During those visits, were you ever told that you have high blood pressure? 1. YES 2. NO 8. DON'T REMEMBER 1. YES 2. NO 8. DON'T REMEMBER 1. YES 2. NO 8. DON'T REMEMBER 343. Did you have any ultrasoud exam during that pregnacy? 1. YES 2. NO ----- >GO TO Q345 8. DON'T REMEMBER->GO TO Q345 1. YES 2. NO ----- >GO TO Q345 8. DON'T REMEMBER->GO TO Q345 1. YES 2. NO ----->GO TO Q345 8. DON'T REMEMBER->GO TO Q345 344. How many months pregnant were you at the time of your (first) ultrasound exam? ________ MTH 88 DON'T REMEMBER OR ________WEEKS ________ MTH 88. DON'T REMEMBER OR ________ WEEKS ________ MTH 88. DON'T REMEMBER OR _______ WEEKS 345. During that pregnancy, did you have any complications that required hospitalization? 1. YES 2. NO ----- >GO TO Q347 8. DON' T` REMEMBER-->GO TO Q347 1. YES 2. NO ----- >GO TO Q347 8. DON' T` REMEMBER-->GO TO Q347 1. YES 2. NO ----->GO TO Q347 8. DON' T` REMEMBER-->GO TO Q347 311 346. Did you have any of the following complications: (READ A-J) YES NO A. Risk of Misacrriage 1 2 B. First Trimester Bleeding 1 2 C. Second Trimester Bleeding 1 2 D. Third Trimester Bleeding 1 2 E. High Blood Pressure 1 2 F. Diabetes 1 2 G Heart Disease 1 2 H. Liver Disease 1 2 I. Urinary Tract Infection 1 2 J. Risk of Preterm Labor 1 2 K. Rli Izoimmunization 1 2 L. Other ---------------------- 1 2 YES NO A. Risk of Misacrriage 1 2 B. First Trimester Bleeding 1 2 C. Second Tnmester Bleeding 1 2 D. Third Tnmester Bleeding I 2 E. High Blood Pressure 1 2 F. Diabetes ! 2 G. Heart Disease 1 2 H. Liver Disease 1 2 I. Urinary Tract Infection 1 2 J. Risk of Preterm Labor 1 2 K. Rh Izoimmunization 1 2 L. Other ---------------------- 1 2 YES NO A. Risk of Misacrriage 1 2 B. First Trimester Bleeding 1 2 C. Second Trimester Bleeding 1 2 D. Third Trimester Bleeding 1 2 E. High Blood Pressure 1 2 I Diabetes 1 2 G. Heart Disease 1 2 II Liver Disease 1 2 I Urinary Tract Infection 1 2 J. Risk of Preterm Labor 1 2 K. Rh Izoimmunization 1 2 L. Other ------------------------ 1 2 347. Was the baby born by vaginal delivery or by cesarean section? 1 VAGINAL DELIVERY-->GO TO Q349 2. CESAREAN SECTION 1. VAGINAL DELIVERY->GO TO Q349 2. CESAREAN SECTION 1 VAGINAL DEI,IVHRY->GO TO Q349 2. CESAREAN SECTION 348. Do you know what was the reason or reasons you had to deliver by cesarean section ? 1. FETOPELVIC DISPROPORTION 2. UNFAVORABLE PRESENT A HON 3. FETAL DISTRESS 4. UTERINE DYSFUNCTION 5. PLACENTA PREVIA OR SEPARATED 6. RUPTURED UTERUS 7. PREECLAMPSIA/ECLAMPSIA 8. DIABETES 9. REPEAT CESAREAN SECTION 88 DON'T KNOW 20. OTHER------------------------ 1. FETOPELVIC DISPROPORTION 2. UNFAVORABLE PRESENT A HON 3. FETAL DISTRESS 4. UTERINE DYSFUNCTION 5. PLACENTA PREVIA OR SEPARATED 6. RUPTURED UTERUS 7. PREECLAMPSIA/ECLAMPSIA 8. DIABETES 9. REPEAT CESAREAN SECTION 88 DON'T KNOW 20. OTHER-------------------------- 1. FETOPELVIC DISPROPORTION 2. UNFAVORABLE PRESENT A HON 3. FETAL DISTRESS 4. UTERINE DYSFUNCTION 5. PLACENTA PREVIA OR SEPARATED 6. RUPTURED UTERUS 7. PREECLAMPSIA/ECLAMPSIA 8. DIABETES 9. REPEAT CESAREAN SECTION 88 DON'T KNOW 20. OTHER-------------------------- 349. How long had you been in labor with that pregnancy (regular contractions 5 apart)? -------------HOURS 88. DON'T REMEMBER -------------HOURS 88. DON'T REMEMBER -------------HOURS 88. DON'T REMEMBER 350. How much did tha babv weigh at birth? --------------------GRAMS 8888 DON'T KNOW --------------------GRAMS 8888 DON'T KNOW --------------------GRAMS 8888 DON'T KNOW 351. During the first 6 weeks after birth, did you have any of the following complications: (READ A-H): YES NO A. Severe Bleeding 1 2 B. Bad-smelling Vaginal Discharge 1 2 C. Infection of Surgical Wound 1 2 D. Faint/coma 1 2 E. High Fever (39-40c) 1 2 F. Disuria 1 2 G. Painful Uterus 1 2 H. Breast Infection I 2 YES NO A. Severe Bleeding 1 2 B. Bad-smelling Vaginal Discharge 1 2 C. Infection of Surgical Wound 1 2 D. Faint/coma 1 2 E. High Fever (39-40c) 1 2 F. Disuria 1 2 G. Painful Uterus 1 2 H. Breast Infection I 2 YES NO A. Severe Bleeding 1 2 B. Bad-smelling Vaginal Discharge 1 2 C. Infection of Surgical Wound 1 2 D. Faint/coma 1 2 E. High Fever (39-40c) 1 2 F. Disuria 1 2 G. Painful Uterus 1 2 H. Breast Infection I 2 IF STILLBRTH GO TO Q359 IN TABLE ABOUT THE LAST BIRTH IF STIL1. BRTH GO TO THE NEXT BIRTH IF STILL BRTH GO TO Q365 352. During the first 6 weeks after birth, did you have any postnatal care visit? 1. YES 2. NO ------ >GOTOQ354 8. DON'T REMEMBER ->GO TO Q3S4 1. YES 2. NO ------ >GOTOQ354 8. DON'T REMEMBER ->GO TO Q3S4 1. YES 2. NO ------>GOTOQ354 8. DON'T REMEMBER ->GO TO Q3S4 353. During those visits did you reveived information about: (READ A-F) YES NO A. BRASTFEEDING 1 2 B. BREAST CARE 1 2 C. CHILD CARE 1 2 D. IMUNIZATION 1 2 E NUTRITION 1 2 F, CONTRACEPTION 1 2 YES NO A. BRASTFEEDING 1 2 B. BREAST CARE 1 2 C. CHILD CARE 1 2 D. IMUNIZATION 1 2 E NUTRITION 1 2 F, CONTRACEPTION 1 2 YES NO A. BRASTFEEDING 1 2 B. BREAST CARE 1 2 C. CHILD CARE 1 2 D. IMUNIZATION 1 2 E NUTRITION 1 2 F, CONTRACEPTION 1 2 354. Did you breatsfeed? 1. YES 2. NO -------->GOTO0 359 1. YES 2. NO->GO TO NEXT BIRTH 1. YES 2. NO -------->GO TO Q365 355. How long after birth did you started breastfeeding? 1. -------- HOURS 777. LESS THAN 1 HOUR 2. --------- DAYS 888. DON'T REMEMBER 1. -------- HOURS 777. LESS THAN 1 HOUR 2. --------- DAYS 888. DON'T REMEMBER 1. -------- HOURS 777. LESS THAN 1 HOUR 2. --------- DAYS 888. DON'T REMEMBER 356. Are you still breastfeeding? YES ------->GO TO Q 358 2. NO 357. How old was the baby when you stopped breastfeeding? 1. --------DAYS 2. ------- MTH 888. DON'T REMEMBER 1. --------DAYS 2. ------- MTH 888. DON'T REMEMBER 1. --------DAYS 2. ------- MTH 888. DON'T REMEMBER 358. How old was the baby when you start feeding with other food than breastmilk? 77. NOT YET _____ MTH 88. DON'T REMEMBER CONTINUE WITH Q359 ____ MTH 88. DON'T REMEMBER GO TO THE NEXT BIRTH ______ MTH 88 DON'T REMEMBER GO TO Q365 312 LAST BIRTH (COPY THE LINE # FROM PAGE 14) 359. Where did you give birth the last time? 1 HOSPITAL, MATERNITY 2 BIRTH HOUSE 3. OTHER MEDICAL FACILITY--------------------- 4. HOME---->GOTOQ363 5. ON THE WAY TO HOSPITAL > GO TO Q363 360. Would you rank the place you gave birth last time as good, lair or poor in the following areas: (READ A-F) A. Hygiene B. Comfort C. Hospital crowdedness D. Permision for visitors E. Competence of health professionals F. Behavior of health professionals GOOD FAIR POOR DON'T KNOW 1 2 3 8 1 2 2 3 8 3 1 2 3 8 1 2 3 8 8 8 1 2 3 8 1 2 3 8 361. With how many women were you sharing the hospital room after birth? ---------------WOMEN 88. DON'T REMEMBER 362. How many days after birth did you leave the hospital? ---------------DAYS 88, DON'T REMEMBER 363. I low many months after birth did your period return? ---------------MONTHS 77. NOT YET 88. DON'T REMEMBER 364. How many months after birth did you resume sexual relations? ---------------MONTHS 77. NOT YET 88. DON'T REMEMBER GO TO NEXT TO LAST BIRTH, PAGE 14 365. CIRCLE WHAT WAS THE OUTCOME OF THE LAST PREGNANCY THAT ENDED BETWEEN 1992-1997 (SEE Q312_l AND Q313B-1 PAGE 9) 1. LIVE BIRTH OR STILLBIRTH 2. INDUCED ABORTION OR MINIABORTION 3. 1VHSSCARIAGE OR ECTOPIC PREGNANCY 366. BEFORE your last pregnancy did your partner or ex-partner physically abuse you in one of the following ways: YES NO DON'T REMEMBER A. Did he push, shove, or slap you? 1 2 8 B. Did he kick you or hit you with his fists or an object? 1 2 8 C. Did he threaten you with a knife or other weapon? 1 2 8 D. Did he beat you up? 1 2 8 E. Did he force you to have sexual intercourse against your will? 1 2 8 367. DURING your last pregnancy did your partner or ex-partner physically abuse you in one of the following ways: YES NO PONT REMEMBER A. Did he push, shove, or slap you? 1 2 8 B. Did he kick you or hit you with his fists or an object? 1 2 8 C. Did he threaten you with a knife or other weapon? 1 2 8 D. Did he beat you up? 1 2 8 E. Did he force you to have sexual intercourse against your will? 1 2 8 368. How about the first 6 months AFTER your last pregnancy,.: YES NO DON'T REMEMBER A. Did he push, shove, or slap you? 1 2 8 B. Did he kick you or hit you with his fists or an object? 1 2 8 C. Did he threaten you with a knife or other weapon? 1 2 8 D. Did he beat you up? 1 2 8 E. Did he force you to have sexual intercourse against your will? 1 2 8 313 IV FAMILY PLANNING KNOWLEDGE/ SEXUAL EXPERIENCE For each of the following methods of preventing pregnancy, please tell me: METHOD 400. Have you ever heard of it? 401. Do you know how to use it? 402. Have you ever used it? 403. Do you know where to get it? 404. From whom did you hear about it? (SEE CODES BELOW) A. Pills 1 Yes->Q401 2 No—>B 1 Yes->Q402 2 No»>Q402 1 Yes\ 2 No / Q403 1 Yes\ 2 No /Q404 -------- B. 1UD 1 Yes-->Q401 2 No—>C 1 Yes->Q402 2 No->Q402 1 Yes\ 2 No / Q403 1 Yes\ 2 No /Q404 -------- C. Condoms 1 Yes»>Q401 2 No—>D 1 Yes-->Q402 2 No-->Q402 1 Yes\ 2 No /Q403 1 Yes\ 2 No / Q404 -------- D. Foam/Jelly/ Cream 1 Yes->Q401 2 No—>E 1 Yes-->Q402 2 No->Q402 1 Yes\ 2 No / Q403 1 Yes\ 2 No / Q404 ------- E. Female Sterilization 1 Yes-->Q401 2 No—>F 1 Yes-->Q402 2 No->Q402 1 Yes\ 2 No / Q403 1 Yes\ 2 No / Q404 ------- F. Vasectomy 1 Yes->Q401 2 No—>G 1 Yes-->Q402 2 No-->Q402 1 Yes\ 2 No / Q403 1 Yes\ 2 No / Q404 ------- G. Norplant 1 Yes->Q401 2 No—>H 1 Yes->Q402 2 No-->Q402 1 Yes\ 2 No / Q403 1 Yes\ 2 No /Q404 -------- H. Injectables (Depo-Provera) 1 Yes-->Q401 2 No—>I 1 Yes->Q402 2 No->Q402 1 Yes\ 2 No /Q403 1 Yes\ 2 No / Q404 ------- I.Rhythm/Calendar 1 Yes-->Q401 2 No—>J 1 Yes-->Q402 2 No->Q402 1 Yes\ 2 No / Q404 -------- J. Withdrawal 1 Yes->Q401 2 No—>Q405 1 Yes«>Q402 2 No—>Q402 1 Yes\ 2 No / Q404 -------- CODES FOR Q404 1. Mother 9. Doctor, Medical Assistant/Nurse 2. Father 10. Teacher 3. Relative 11. Books 4. Boyfriend 12. Newspapers, magazines, brochures 5. Friend 13. TV 6. Co-Worker 14. Radio 7. Partner/Husband 20. Other (specify): ___________ 8. Someone who uses it 88. Don't remember 314 405. Looking at this CARD, please tell me which do you think is the most effective contraceptive method? (SHOW CARD A) 1 Pills 2 IUD 3 Condom 4 Foams/jelly/creams 7 Female Sterilization 8 Norplant 9 Injectables (Depo-provera) 11 Rhythm Method 12 Withdrawal 19 Douching after Intercourse 77 NONE OF THEM 88 DON'T KNOW/NOT SURE 406. For each of these methods on CARD A, please tell me how effective it is in pregnancy whittle used correctly; please tell has is high, medium, or low effectiveness: HIGH. MEDIUM LOW DON'T EFFEC1VENESS EFFECIVENESS HFFECIVENESS KNOW 1. PILLS. 1 2 3 8 2. IUD . 1 2 3 8 3. CODOM . 1 2 3 8 4. FOAMS/JELLY/CREAMS . 1 2 3 8 7. FEMALE STERILIZATION . 1 2 3 8 8. NORPLANT . 1 2 3 8 9. DEPO-PROVERA. 1 2 3 8 11. RHYTHM METHOD . 1 2 3 8 12. WITHDRAWAL . 1 2 3 8 19. DOUCHING AFTER INTERCOURSE …………………. 1 2 3 8 IF RESPONDENT IS 15-24 YEARS OF AGE CONTINUE; IF SHE IS 25-44 YEARS GO TO Q420 PAGE 20 408. How old were you when you had your first menstruation -------------- _ AGE 00. NOT YET 88. DON'T REMEMBER 99. REFUSE TO ANSWER 409. Did you know what menstruation was at that time? 1. YES 2. NO 8. NOT SURE 410. Now I have some questions about your first sexual intercourse. When did you have sexual intercourse for the first time - in what month and year was that? (PROBE: Can you tell me what year that was?) A………………….MONTH B……………. YEAR 00. NEVER HAD SEXUAL INTERCOURSE->GO TO 98. DON'T REMEMBER Q601 99. REFUSE TO ANSWER 411. How old were you at that time? ______ _____ YEARS 88. DON'T REMEMBER/DON'T KNOW 315 412. At the time you first had sexual intercourse, what was your relationship to your partner? 1. HUSBAND 2. FIANCEE, ENGAGED TO BE MARRIED 3. BOYFRIEND 4. FRIEND 5. ACQUAINTANCE 6. JUST MET 7. RELATIVE 8. FORCED INTERCOURSE / RAPE —> GO TO Q421 20. OTHER (SPECIFY)_______________ 88. DON'T REMEMBER 413. How old was your first partner? ________YEARS 88. DK/DR 414. How long were you and your first partner dating when you first had sexual relations? 1.____ DAYS OR 2.____ WEEKS OR 3. ___ MONTHS OR 4. ____ YEARS 000=FIRST TIME WE MET 888=DONT REMEMBER 999=NO RESPONSE 777=OTHER___________ 415. Before you had sex for the first time, did you and your partner ever talk about using contraception? 1. YES 2. NO 8. DON'T REMEMBER 416. At the time you had first sexual intercourse, did you or your partner use any contraceptive method? 1.YES 2.NO ->GO TO Q419 8.DK —>GO TO Q421 9 REF—>GO TO Q421 417. Which contraceptive method did you or your partner use at the first intercourse? 1 PILLS 2 IUD 3 CONDOM 4 FOAM/JELLY/CREAM/VAGINAL FILMS 8 NORPLANT 9 INJECTABLES 11 CALENDAR METHOD 12 WITHDRAWAL 19 DOUCHE 20 OTHER: ___________________ 77 NONE 88 DON'T KNOW/DON'T REMEMBER 418. Who made then decision to use contraception at that time? (READ 1-3) 1. You 2. Your partner 3. Both you and your partner 8. Don't remember GO TO Q421 316 419. What was the main reason for not using a contraceptive method at that time? 1 SEX WAS NOT EXPECTED 2 THOUGHT IT WAS A SAFE TIME OF THE MONTH 3 COULD NOT FIND A CONTRACEPTIVE METHOD/UNAVAILABLE/DIFFICULT TO GET 4 RESPONDENT WAS AGAINST IT 5 PARTNER WAS AGAINST IT 6 DID NOT KNOW ABOUT CONTRACEPTION 7 WANTED TO GET PREGNANT 8 DID NOT WANT TO USE A METHOD 9 DID NOT THINK ABOUT USING A METHOD 10. NEGLIGENCE 20. OTHER (SPECIFY) __________ 88. DON'T REMEMBER/DON'T KNOW GO TO Q421 420. How old were you at the time of your first sexual intercourse? ______ YEARS 00. NEVER HAD INTERCOURSE—>GO TO Q601 PAGE 29 88. DK/DR 421. During the past 30 days (past month) have you had sexual intercourse? 1. YES —>GO TO Q423 2. NO 9. REF 422. During the past 3 months, have you had sexual intercourse? 1. YES 2. NO —>GO TO Q424 9. REF —>GO TO Q424 423. During the past 3 months, with how many different partners have you had intercourse? _____ PARTNERS 88. DK 99. NR 424. In your lifetime, with how many different partners have you had intercourse? ______ PARTNERS 88. DK 99. NR 425. When was the last time you had sexual intercourse? ____ MONTH 19____YEAR 98. DK 99.NR 317 V. CURRENT AND PAST CONTRACEPTIVE USE 501. RECORD WHETHER RESPONDENT REPORTED HAVING USED ANY METHOD (ANY Q402=l) 1 NEVER USED (NO Q402=l) 2 EVER USED (ANY 0402=1)—>GO TO Q503 502. So, you said that you or any of your partners have never used any method to prevent pregnancy? 1 NEVER USED—>GO TO Q514 PAGE 23 2 EVER USED—>CORRECT Q402 THEN CONTINUE 503. Are you (or your partner) currently using (in the last 30 days) any method or doing anything to prevent pregnancy? 1 YES 2 NO—>GO TO Q514 PAGE 23 504. What method are you currently using? 1. PILLS 2. 1UD 3. CONDOM ---------------------------- >GO TO Q506 4. FOAM/JELLY/CREAMS 5. CONDOM + SPERMICIDE—>GO TO Q506 6. CONDOM +WITHDRAWAL/CALENDAR->GO TO Q506 7. FEMALE STERILIZATION 8. NORPLANT 9. INJECTABLES(DEPO PROVERA) 10. OTHER MODERN METHODS ……………………. 11. CALENDAR 12. WITHDRAWAL 13. WITHDRAWAL AND CALENDAR 20. OTHER TRADITIONAL METHODS ……………… 88. NOT SURE 505. In the last 30 days, did you and your partner ever use a condom in addition to the method you are using? 1 YES 2 NO 506. In the last 30 days did you/your partner use (METHOD FROM Q504) every time you had sexual intercourse? 1 YES 2 NO BOX 5-1 IFQ504 = 1-10, OR 88 GO TO Q509; IF SHE USES NATURAL METHODS (Q504 =11-20), CONTINUE 507. Please tell me whether each of the following reasons was very important, somewhat important, or not important at all in your decision to use a traditional method instead of a modern method: Very Somewhat Not Not Important Important Important Sure A. Difficult to get these methods 1 2 3 8 B. Cost of these methods 1 2 3 8 C. Little knowledge of these methods 1 2 3 8 D. Health /Side effects 1 2 3 8 E. Husband/Partner preference 1 2 3 8 F. Religious beliefs 1 2 3 8 G. Doctor's recommendation 1 2 3 8 318 508. How effective at preventing pregnancy do you think_________________ ( FILL IN THE METHOD USED) is compared to modern methods, like the pill or the IUD? (READ 1-3) 1 Current method more effective 2 About equally effective 3 Current method less effective 8 DON'T KNOW/NOT SURE 509. Would you prefer to use a different method of family planning from the one you are currently using? 1 YES 2 NO—>GO TO Q512 510. What method would you prefer to use? 1. PILLS 2. IUD 3. CONDOM 4. FOAM/JELLY/CREAMS 5. CONDOM+SPERMICIDE 6. CONDOM +WITHDRAWAL/CALENDAR 7. FEMALE STERILIZATION 8. NORPLANT 9. INJECTABLES(DEPO PROVERA) 10. OTHER MODERN METHODS _______________ 11. CALENDAR 12. WITHDRAWAL 13. WITHDRAWAL AND CALENDAR 20. OTHER TRADITIONAL METHODS ___________ 88. NOT SURE 511. What is the most important reason that you do not use that method? 1 DOCTOR WILL NOT PRESCRIBE IT 2 COST 3 NOT AVAILABLE/UNRELIABLE SUPPLIES/DIFFICULT ACCESS 4 TOO FAR AWAY 5 DO NOT KNOW HOW TO OBTAIN IT 6 HUSBAND/PARTNER OBJECTS TO IT 7 RELIGIOUS REASONS 8 FEAR OF SIDE EFFECTS 9 HAS NOT YET MADE UP HER MIND 20 OTHER _________________________ 88 DON'T KNOW 512. Do you have any problems or concerns with using your current method? 1 YES 2 NO—>GO TO Q519 513. What is the most important problem? 1 SIDE EFFECTS 2 HEALTH CONCERNS 3 ACCESS/AVAILABILITY 4 COST 5 SOMETIMES FORGET TO USE 6 SOMETIMES DIFFICULT/INCONVENIENT TO USE 7 HUSBAND/PARTNER DISAPPROVES 8 LESS EFFECTIVE METHOD/GOT PREGNANt WHILE USING IT 20 OTHER…………………… 88 DK7DR BOX 5-II GO TO Q519 PAGE 24 319 514. What is the main reason that you or your partner are not currently using a contraceptive method? 1. DOES NOT CURRENTLY HAVE A PARTNER/ NOT SEXUALLY ACTIVE IN THE LAST MONTH 2. TRYING TO GET PREGNANT 3. POSTPARTUM/BREASTFEEDING 4. CURRENTLY PREGNANT 5. HYSTERECTOMY/MENOPAUSE . >GO TO Q519 6. DOCTOR SAID HER PARTNER CANNOT HAVE CHILDREN -----> GO TO Q519 7. SHE/COUPLE TRIED TO GET PREGNANT FOR AT LEAST 2 YEARS AND DID NOT SUCCEED 8. FEAR OF SIDE EFFECTS 9. CONCERNED ABOUT LONG TERM HEALTH PROBLEMS 10. LOVEMAKING WOULD BE INTERRUPTED 11. BIRTH CONTROL IS DIFFICULT TO USE 12. BIRTH CONTROL IS TOO MESSY 13. CANNOT AFFORD BIRTH CONTROL (COSTS TOO MUCH) 14. BIRTH CONTROL IS DIFFICULT TO GET (TOO FAR AWAY) 15. BIRTH CONTROL IS NOT (VERY) EFFECTIVE 16. RESPONDENT DOES NOT WANT TO USE A METHOD 17. PARTNER OBJECTS TO USING METHOD 18. OBJECTS DUE TO RELIGIOUS REASONS 19. DOES NOT KNOW WHERE TO GET METHOD 20. DOES NOT KNOW HOW TO USE BIRTH CONTROL METHODS 21. RESPONDENT DOES NOT THINK SHE CAN GET PREGNANT 22. DIDN'T THINK ABOUT IT 23. NEGLIGENCE 77. OTHER (SPECIFY) ----------------- 88. DK 515. Do you think that you will use a contraceptive method during the next 12 months? I YES--------> GO TO Q517 2. NO 8. NOT SURE 516. Do you think that you will use a contraceptive method any time in the future? 1. YES 2. NO ------- > GO TO Q519 8. NOT SURE --------> GO TO Q519 517. What method would you want to use most? 1. PILLS 2. IUD 3. CONDOM 4. FOAM/JELLY/CREAMS 5. CONDOM+SPERMICIDES 6. CONDOM +WITHDRAWAL/CALENDAR 7. FEMALE STERILIZATION 8. NORPLANT 9. INJECTABLES(DEPO PROVERA) 10. OTHER MODERN METHODS ________________ 11. CALENDAR ---------------------------------------------------------->GO TO Q519 12. WITHDRAWAL------------------------------------------------------>GO TO Q519 13. WITHDRAWAL AND CALENDAR ----------------------------->GO TO Q519 20. OTHER TRADITIONAL METHODS ………………………. >GO TO Q519 88. NOT SURE ------------------------------------------------------------ >GO TO Q519 320 518. On average, how much are you willing to pay for contraception, per month? __________ Lei 888= NOT SURE/DON'T KNOW 519. During the last year, how often did you talk about contraception with your husband/ partner? 1. NEVER---------------------------- >GO TO Q521 2. ONE OR TWO TIMES 3. THREE TIMES OR MORE 4. RESPONDENT HAD NO PARTNER DURING THE LAST YEAR----------->GO TO Q521 520. Generally, does your husband/ partner approve or disapprove with the use of contraceptive methods? 1. APPROVE 2. DISAPPROVE 8. NOT SURE/DON'T KNOW 521. Some people use condoms for reasons other than birth control, for instance because they are concerned about getting diseases that can result from sexual intercourse. Have you ever used condoms with a partner only for birth control, only to prevent diseases, or have you used them for both reasons? 1. BIRTH CONTROL ONLY ----------- >GO TO BOX 5-III 2. DISEASE PREVENTION ONLY—>GO TO BOX 5-III 3 BOTH ----------- >GO TO BOX 5-III 4. NEVER USED CONDOM 8. OTHER ___________________ 522. Why have you and your partner(s) never used condoms? 1. PREVENTING PREGNANCY IS WOMAN'S RESPONSIBILITY 2. PARTNER(S) OBJECTED TO USE CONDOMS 3. HAVE ONLY ONE PARTNER 4. THEY ARE ONLY FOR USE WITH PROSTITUTES 5. THEY ARE ONLY FOR USE OUTSIDE MARRIAGE(COUPLE) 6. CONDOMS DIMINISH PLEASURE/SPONTANEITY 7. CONDOMS ARE NOT EFFECTIVE IN PREVENTING PREGNANCY 8. CONDOMS ARE BAD FOR YOUR HEALTH? 9. CONDOMS ARE TOO DIFFICULT TO USE 10. LOVEMAKING WOULD BE INTERRUPTED 11. CONDOM USE IS TOO MESSY 12. CONDOMS ARE EXPENSIVE 13. SHE HAS NEVER THOUGHT ABOUT IT 14. PSYCHOLOGICAL RESISTANCE 15. PREFERS WITHDRAWAL 20. OTHER __________________________________ 88. DON'T KNOW BOX 5-III > IF RESPONDENT HAS USED ANY CONTRACEPTIVE METHOD SINCE JANUARY 1992, FILL IN ALL FOUR COLUMNS OF THE CONTRACEPTIVE CALENDAR > IF NO METHOD HAS BEEN USED SINCE JANUARY 1992, FILL IN ONLY COLUMN 1 (SEE ALSO PREGNANCY HISTORY AT PAGE 9) AND COLUMN 4 (SEE ALSO MARITAL STATUS AT PAGE 3) AND WRITE "0" AT THE BEGINNING AND THE END OF THE SECOND AND THIRD COLUMNS 321 523. CONTRACEPTIVE METHODS USED/PREGNANCY OUTCOMES/AND MARITAL STATUS CALENDAR COLUMN 1 PREGNANCY OUTCOME 1 PREGNANT THAT MONTH 2 LIVE BIRTH 4 STILLBIRTH 6 MISCARRIAGE 7 INDUCED ABORTION 8 MINIABORTION 9 ECTOPIC PREGNANCY COLUMN 2 METHOD USED 0. NO METHOD 1. PILL 2. IUD 3. CONDOM 4. SPERMICIDES 5. CONDOM+ SPERMICIDES 6. CONDOM+ CAL./WITHDRAWAL 7. TUBAL LIGATION 8. NORPLANT 9. DEPO-PROVERA 10. OTHER MODERN MET. ___________ 11. CALENDAR 12. COITUS INTERUPTUS (WITHDRAWA) 13. COITUS INTERUPTUS + CALENDAR 20. OTHER TRADITIONAL MET.________ 88. DO NOT REMEMBER COLUMN 3 REASON STOPPED USING A METHOD 1. GOT PREGNANT WHILE USING 2. WANTED TO GET PREGNANT 3. HUSBAND OBJECTED 4. SIDE EFFECTS 5. HEALTH CONCERNS 6. STOPPED TO "REST THE BODY" 7. PHYSICIAN DECISION 8. SUPPLY/AVAILABILITY 9. DIFFICULT/INCONVENIENT TO USE 10. MARRIAGE/RELATIONSHIP ENDED 11. WANTED TO TRY OTHER METHOD 20. OTHER ___________________ COLUMN 4 (MARITAL STATUS) 0. NOT MARRIED/NOT IN UNION 1. MARRIED/IN UNION DATE 1 2 3 4 DATE 1 2 3 4 1992 1995 1 Jan 1 Jan 2 Feb 2 Feb 3 Mar 3 Mar 4 Apr 4 Apr 5 May 5 May 6 Jun 6 Jun 7 Jul 7 Jul 8 Aug 8 Aug 9 Sep 9 Sep 10 Oct 10 Oct 11 Nov 11 Nov 12 Dec 12 Dec 1993 1996 1 Jan 1 Jan 2 Feb 2 Feb 3 Mar 3 Mar 4 Apr 4 Apr 5 May 5 May 6 Jun 6 Jun 7 Jul 7 Jul 8 Aug 8 Aug 9 Sep 9 Sep 10 Oct 10 Oct 11 Nov 11 Nov 12 Dec 12 Dec 1994 1997 1 Jan 1 Jan 2 Feb 2 Feb 3 Mar 3 Mar 4 Apr 4 Apr 5 May 5 May 6 Jun 6 Jun 7 Jul 7 Jul 8 Aug 8 Aug 9 Sep 9 Sep 10 Oct 10 Oct 11 Nov 11 Nov 12 Dec 12 Dec IF SHE DID NOT USE A METHOD IN JANUARY 1992, GO TO Q525 524. You said you were using _____ in January of 1991. When did you start using that method? A. MONTH_____ B. YEAR 19____ 98.DK/REF 322 525. LAST CONTRACEPTIVE METHOD USED (COPY THE METHOD FROM THE CONTRACEPTIVE CALENDAR): 1. PILLS 9. DEPO-PROVERA 2. IUD 10. OTHER MODERN METHOD 3. CONDOM 11. CALENDAR ---------------------------- >GO TO BOX 5-IV 4. FOAM/JELLY/CREAMS 12. WITHDRAWAL ------------------------>GO TO BOX 5-IV 5. CONDOM +SPERMICIDES 13. WITHDRAWAL+CALENDAR------->GO TO BOX 5-IV 6. CONDOM +WITHDRAWAL/CALENDAR 20. OTHER TRADITIONAL MET. ------->GO TO BOX 5-IV 7. FEMALE STERILIZATION 88. DO NOT REMEMBER ---------------->GO TO BOX 5-IV 8. NORPLANT 526. The next following questions concern the last contraceptive method you have used. Where did you get that method? 1. VILLAGE DISPENSARY 8. STORE/DRUGSTORE 2. MEDICAL CIRCUMSCRIPTION CLINIC 9. PARTNER 3. WOMEN'S CONSULTATION CLINIC 10. FRIEND 4. HOSPITAL/MATERNITY/GYN WARD 11. RELATIVE 5. PHARMACY 20. OTHER (SPECIFY): _____________________ 6. OPEN MARKET 88. DON'T KNOW 527 Do (Did) you pay for this method? 1 YES 2 NO------>GO TO Q529 3 PARTNER GETS THE METHOD------ >GO TO Q529 528. How much did you pay?_______________ Lei 888= DOES NOT REMEMBER 529. At the time you started using the last contraceptive method, who advised you about how to use that method? 1. PHYSICIAN 6. FRIEND --------------------------- >GO TO BOX 5-IV 2. NURSE/MIDWIFE 7. PARTNER ------------------------ >GO TO BOX 5-IV 3. PHARMACIST------------>GO TO BOX 5-IV 8. NOBODY -------------------------->GO TO BOX 5-IV 4 MOTHER------------------>GO TO BOX 5-IV 20 OTHER _______________ ---- >GO TO BOX 5-IV 5. OTHER RELATIVE ---->GO TO BOX 5-IV 530. When you received the information concerning use of the method, did the heath provider tell you about other contraceptive methods? 1 YES 2 NO--------- >GO TO Q532 531. Did the health provider explain how effective that method is compared to other contraceptive methods? 1 YES 2 NO 532. Did the health provider explain the possible side effects of the method? 1 YES 2 NO 533. Overall, would you say you have been very satisfied, satisfied, somewhat satisfied, not satisfied or not at all satisfied with the family planning services you have received? 1. Very satisfied 2. Satisfied 3. Somewhat satisfied 4. Not satisfied 5. Not at all satisfied BOX 5-IV IF A CONTRACEPTIVE METHOD WAS USED IN THE LAST MONTH (LAST CELL IN COLUMN 2 IS NOT "0 ") THEN GO TO Q536; ELSE CONTINUE 323 534. Do you think you are physically able to get pregnant at the present time? 1. YES—>GO TO Q536 2 NO 3 NOT SURE 4 CURRENTLY PREGNANT—>GO TO Q536 535. What is the main reason why you think you cannot get pregnant? 1. RESPONDENT DOES NOT HAVE A PARTNER/ IS NOT SEXUALLY ACTIVE 2. CURRENTLY BREAST-FEEDING /POSTPARTUM 3. HYSTERECTOMY 4. MENOPAUSE 5. OVARIAN CYSTS/ OVARIAN DYSFUNCTION 6. RESPONDENT HAD BOTH TUBES REMOVED OR OBSTRUCTED 7. PELVIC INFLAMATORY DISEASE (PID) 8. ENDOCRIN DYSFUNCTION OR OTHER SYSTEMIC DISEASES 9. OTHER MEDICAL CAUSES THAT MAKES PREGNANCY IMPOSSIBLE 10. HAS TRIED TO GET PREGNANT IN THE PAST 2 YEARS AND DID NOT SUCCEED 11. PARTNER HAD A MEDICAL OPERATION AND CANNOT HAVE CHILDREN 12. PARTNER IS INFERTILE 13. CURRENTLY USES A METHOD (GO BACK TO Q504 AND CORRECT IT) 20. OTHER (SPECIFY) _________ 88. DK 99. REF 536. In the past 12 months have you ever wanted to get/obtain condoms? 1 YES 2 NO ------------------ >GO TO BOX 5-V 3. DID NOT KNOW WERE SHE CAN GET CONDOMS ------------------->GO TO BOX 5-V 537. In the past 12 months, did you succeed in getting/obtaining condoms? 1 YES ----------------- >GO TO BOX 5-V 2 NO 533. What was the reason you were unable to get condoms? 1. CONDOMS UNAVAILABLE/OUT OF STOCK 2. COST 3. HARD TO FIND/DID NOT HAVE TIME TO LOOK FOR THEM 4. EMBARRASSED TO ASK FOR THEM IN A PHARMACY/FP CLINIC 7. OTHER (SPECIFY)_______________________ 8. DON'T REMEMBER BOX 5-V IF RESPONDENT IS CURRENTLY PREGNANT (Q300=1) GO TO Q540; ELSE CONTINUE 324 539. Looking to the future, do you yourself intend to have (a/another) baby at some time? 1. WANT A BABY —>GO TO Q541 2. DO NOT WANT A BABY —>GO TO Q542 3. RESPONDENT AND PARTNER DISAGREE —> GO TO Q542 8 DK —>GO TO Q542 540. Looking to the future, do you yourself intend to have another baby after this pregnancy? 1. YES 2. NO —> GO TO Q542 3. RESPONDENT AND PARTNER DISAGREE —> GO TO Q542 8. DK — > GO TO Q542 541. When do you, yourself actually want to get pregnant (again).(READ 1-5) 1. you want to get pregnant now, 2. within the next 12 months, 3. In 1-2 years, 4. In 3-5 years, 5. or after 5 years? 8. DK GO TO MODULE VI 542. Are you interested in having an operation to prevent you from having any more children? 1 YES ---------->GO TO MODULE VI 2 NO 3 ALREADY STERILIZED----------->GO TO MODULE VI 8. NOT SURE 543. What is the most important reason you wouldn't be/are not interested? 1. HEALTH RISKS/FEAR OF SIDE EFFECTS 2. FEAR OF OPERATION 3. DOESN'T KNOW ENOUGH ABOUT /NEVER HEARD OF STERILIZATION 4. MIGHT WANT ANOTHER CHILD 5. COST 6. DOES NOT HAVE A PARTNER/NOT SEXUALLY ACTIVE 7. TOO YOUNG OR TOO OLD (APPROACHING MENOPAUSE) 8. HAVEN'T THOUGHT ABOUT IT 9. NOT CULTURALLY ACCEPTABLE 10. RELIGIOUS REASONS 11. CANNOT GET PREGNANT 12. PREFERS OTIIER METIIODS 20. OTHER ………………………………………… 88. DON'T KNOW 325 VI. WOMEN'S HEALTH 601. Have you ever had a gynecologic exam? 1 YES—>GO TO Q603 2. NO 9. NR 602. What is the principle reason that you have not had a routine gynecologic exam? 1. DOES NOT NEED TO GO TO GYNECOLOGIC EXAM 2. SHE IS HEALTHY AND HAS NOT GYNECOLOGIC PROBLEMS 3. THERE IS NOT TIME TO GO FOR EXAM 4. SHE FORGETS ABOUT IT 5. SHE DOES NOT LIKE GYNECOLOGIC EXAM 6. IT IS DIFFICULT TO GET APPOINTMENT 7. DOES NOT LIKE PLACE/FACILITY 8. DOES NOT LIKE THE STAFF 9. WAITING TIME IS TOO LONG 10. DOCTOR DID NOT RECOMMEND 11. SHE IS EMBARRASED TO HAVE GYNECOLOGIC EXAM 12. NEVER THOUGHT ABOUT IT 13. NOT SEXUALLY ACTIVE 14. VIRGIN 20. OTHER ______________ 88. DK 99. NR GO TO Q604 603. How often do you go for regular (not pregnancy related) gynecologic exams? (READ 1-4) 1. At least once per year 2. Every 1-2 years 3. Every 3-5 years 4. Less than every 5 years 8. DK/DR 604. Have you ever had a Pap smear? (PROBE: A pap smear is a test that takes a sample of cells from the cervix, or opening to the uterus, to detect cancer) 1. YES—>GOTOQ606 2. NO 8. DK 9. REF 605. What is the main reason you have never had a Pap smear? 1. NEVER HEARD OF IT 2. DOCTOR HAS NOT RECOMMENDED IT 3. SHE IS HEALTHY AND HAS NO GYNECOLOGIC PROBLEMS 4. SHE DOES NOT FEEL TEST IS NECESSARY 5. DOES NOT HAVE TIME TO GO FOR A TEST/ SHE FORGETS ABOUT IT 6. NEVER THOUGHT OF IT 7. SHE IS AFRAID OF THE RESULTS 8. SHE IS AFRAID IT COULD BE PAINFUL 9. TOO EMBARRASSED TO GET THE TEST OR A PELVIC EXAM. 10. SHE HAD NO PARTNER/ NOT SEXUALLY ACTIVE 20. OTHER (SPECIFY): ___________________________ 88. DON'T KNOW 99. REFUSE TO ANSWER GO TO Q607 326 606. When did you have your last Pap smear? Was it.(READ 1-4) 1. within the last year, (O TO 11 MONTHS AGO) 2. 1 to 2 years ago, (12 TO 23 MONTHS AGO) 3. 2-3 years ago, (24 to 35 MONTHS AGO) 4. more than 3 years ago? (36+MONTHS AGO) 8. DON'T KNOW 607. Have you heard about breast self-examinations? 1 YES 2 NO ------------------ >GO TO Q610 608. Do you ever do breast self-examinations? 1 YES 2 NO ------------------->GO TO Q610 609. How often do you do it, on average? 1 Once a month/After each menstruation 2 Every 2-5 months 3 Every 6-11 months 4 Once per year or less 610. Have you ever tried cigarette smoking, even one or two puffs? I. YES 2 NO—> GO TO 617 611. How old were you when you smoked a cigarette for the first time? ….YEARS 88. DK 99.NR 612. Have you smoked at least 100 cigarettes in your entire life? (PROBE: 100 cigarettes is about 5 packs) 1. YES 2 NO—> GO TO 617 8. DK—> GO TO 617 9. REE—>GO T0 617 613. How old were you when you first started smoking fairly regularly? ______YEARS 00 NEVER SMOKED REGULARLY 99 NR 614. During the last 30 days, days did you smoke cigarettes: (READ 1-4) 1. Every Day 2. Almost Every Day 3. Some Days 4. Not at All in the last 30 days-->GO TO Q616 9. REF----------->GO TO Q616 615. During the last 30 days, on the days you smoked, how many cigarettes did you smoke per day? 1. 1 CIGARETTES PER DAY 2. 2-5 CIGARETTES PER DAY 3. 6-10 CIGARETTES PER DAY 4. 4 11-19 CIGARETTES PER DAY 5. 20 OR MORE CIGARETTES PER DAY GO TO Q617 327 616. In what month and year did you last smoke cigarettes at all? (PROBE FOR SEASON IF MONTH IS UNKNOWN) _______MONTH ________________ YEAR 88. DK 99. REF 617. Now, 1 will ask you about some medical conditions that may affect a pregnant women? Has a doctor ever told you that you have. Yes No DK REF A. Diabetes? . 1 2 8 9 B. High blood pressure? . 1 2 8 9 C. Anemia? . 1 2 8 9 D. Heart Disease? . 1 2 8 9 E. Hepatitis B? . 1 2 8 9 F. PID (salpingitis or endometritis). 1 2 8 9 G. Urinary infection?. 1 2 8 9 H. Asthma . 1 2 8 9 Now, 1 have some questions about drinking alcohol. We count a drink as one can or bottle of beer, one glass of wine, or one shot of liquor, vodka, or wiskey. (BOTTLE OF BEER=330-500ML; GL.ASS OF WINE = 150-200 ME; SHOT OF LIQUOR=50ML) 618. In the past 3 months, on the days that you drank alcohol, how many drinks did you usually have? …………….# OF DRINKS 00. NO DRINKS/ONLY FEW SIPS—> GO TO MODULE VII 88 DK ---- > GO TO MODULE VII 99 REF -> GO TO MODULE VII 619. How often did you drink that amount? (PROBE: How many times a week, a month) 1. EVERYDAY 2. ALMOST EVERY DAY 3. I-2 TIMES A WEEK 4. 2-3 TIMES A MONTH 5. ONCE A MONTH 6. 1-2 TIMES IN THREE MONTHS 620. In the past 3 months, have there been days when you had more than usual (# FROM Q618 drinks)? 1. YES 2. NO —> GO TO MODULE VII 8. DK —> GO TO MODULE VII 9. REF -> GO TO MODULE VII 621. In the past 3 months, how many drinks did you have on the days that you drank more than usual (# FROM Q618)? (CHECK IF # FROM Q621># FROM Q618) _________ # OF DRINKS 88 DK -> GO TO MODULE VII 99 REF -> GO TO MODULE VII 622. How often did you drink that amount? 1. EVERYDAY 2. ALMOST EVERY DAY 3. 1-2 TIMES A WEEK 4. 2-3 TIMES A MONTH 5. ONCE A MONTH 6. 1-2 TIMES IN THREE MONTHS 328 VII REPRODUCTIVE HEALTH KNOWLEDGE/ATTITUDES 700. What do you think is the ideal number of children for a young family in Moldova? 0. 0 CHILDREN 6. 3-4 CHILDREN 1. 1 CHILD 7. 4 CHILDREN 2. 1-2 CHILDREN 8. 5 OR MORE 3. 2 CHILDREN 9. GOD KNOWS 4. 2-3 CHILDREN 77. AS MANY AS POSSIBLE 5. 3 CHILDREN 88. DON'T KNOW 701. When is it most likely for a woman to become pregnant (READ 1 -5) ? 1 Just before menstruation starts 2 During menstruation 3 Right after menstruation ends 4 Halfway between her periods 5 It doesn't matter, all times alike 7 Other (SPECIFY) ______________________ 8 DON'T KNOW 702. Do you think that breastfeeding increases, decreases or has no effect on a woman's risk to get pregnant? 1. INCREASES THE RISK 2. DECREASES THE RISK 3. HAS NO EFFECT 8. DO NOT KNOW 703. Do you think that a woman always has the right to decide about her pregnancy, including whether or not to have an abortion? 1 YES—>GO TO Q705 2 NO 704. Under which of the following conditions is it all right for a woman to have an abortion (READ A-F) ? YES NO DEP. DK A. Her life is endangered by the pregnancy. 1 2 3 8 B. The fetus has a physical deformity . 1 2 3 8 C. The pregnancy has resulted from rape . 1 2 3 8 D. Her health is endangered by the pregnancy . 1 2 3 8 E. She is unmarried . 1 2 3 8 F. The couple cannot afford to have a child . 1 2 3 8 705. If a woman had a unwanted pregnancy what should she do? (READ 1-3): 1 Have the baby and keep it 2 Have the baby and give it up for adoption 3 Have an abortion 8 DON'T KNOW 329 706. I would like to know if you are in agreement with the following statements (READ A-H): DON'T AGREE AGREE DK A. A woman can become pregnant the first time she has sexual intercourse . 1 2 8 B. All people should get married . 1 2 8 C. Many young people have sex because their friends are sexually active . 1 2 8 D. Men are not interested in discussing contraception with their partner/wives . 1 2 8 E. Females are not interested in discussing contraception with their partner/hus . 1 2 8 F. A woman must have the children that GOD gives her . 1 2 8 G. Child care is a woman job . 1 2 8 H. A woman should be a virgin when she marries . 1 2 8 707. Who do you think should decide how many children a couple should have (READ 1-3)? 1. The woman, 2. The man, or 3. Both? 8 DON'T KNOW 708. How would you rank each of the following birth control methods (SHOW LIST B) with regard to the risk of side effects; please tell me if the risk is low, medium, or high: LOW MEDIUM HIGH RISK RISK RISK DK 1. PILL . 1 2 3 8 2. IUD . 1 2 3 8 3. CONDOM . 1 2 3 8 4. TUBAL LIGATION. 1 2 3 8 5. INJECTABLES (Ex. DEPO-PROVERA) . 1 2 3 8 6. INDUCED ABORTION . 1 2 3 8 7. MINIABORTION . 1 2 3 8 BOX 7-1 IF Q400_A=2 (NEVER HEARD OF PILLS), GO TO BOX VII-2 709. Please tell me if you agree or disagree with the following statements about birth control pills (READ A-J): AGREE DISAGREE DK A. Pills are easy to use. 1 2 8 B. Pills are easy to get . 1 2 8 C. Pills are too expensive . 1 2 8 D. It is stressful to remember to take the pill every day . 1 2 8 E. Pills allow spontaneity of sexual intercourse . 1 2 8 F. Pills protect against some gynecologic cancers . 1 2 8 G. Pills diminish sexual enjoyment . 1 2 8 H. Pills make women's periods more regular . 1 2 8 I. Pills decrease blood loss during menstruation . 1 2 8 J. Pills decrease menstrual cramps and pain . 1 2 8 330 710. Please tell me if using birth control pills, a woman's risk for the following conditions is increased, decreasec or not affected (READ A-J): INCREASED DECREASED NOT RISK RISK AFFECTED DK A. Cancer . 1 2 3 8 B. High Blood Pressure . 1 2 3 8 C. Myocardial Infarction or other heart disease . 1 2 3 8 D. Trombophlebitis . 1 2 3 8 E. Weight Gain . 1 2 3 8 F. Sexually Transmitted diseases. 1 2 3 8 G. Infertility . 1 2 3 8 H. Depression . 1 2 3 8 I. Headaches, migrene. 1 2 3 8 J. Ectopic Pregnancy . 1 2 3 8 BOX 7-11 IFQ400B=2 (NEVER HEARD ABOUT IUD), GO TO Q713 711. Please tell me if you agree or disagree with the following statements about IUDs (READ A-D): AGREE DISAGREE DK A. The IUD is a relatively inexpensive method to use . 1 2 8 B. The IUD is stressful because it means to have "a foreign device " in your body . 1 2 8 C. The use of IUD can cause spotting between periods . 1 2 8 D. The use of IUD increases menstrual pain . 1 2 8 712. Please tell me if using an IUD, a woman's risk for the following conditions is increased, decreased, or not affected (READ A-J): INCREASED DECREASED NOT RISK RISK AFFECTED DK A. Cancer . 1 2 3 8 B. Pelvic Inflammatory Disease. 1 2 3 8 C. Infertility . 1 2 3 8 D. Abdominal Pain . 1 2 3 8 E. Prolonged Menstrual Bleeding . 1 2 3 8 F. Ectopic Pregnancy . 1 2 3 8 713. Some people use condoms to keep from getting sexual transmitted diseases. How effective do you think a properly used condom is for this purpose? (READ 1-4) 1. Very Effective 2. Somewhat effective 3. Not very effective 4. Not at all effective 8. DON'T KNOW 331 714. Do you want to have more information about contraceptive methods? 1. YES 2 NO -----------> GO TO BOX VII-3 8 DON'T KNOW —> GO TO BOX VII-3 715. Who do you think would be the best person to give you information about contraceptive methods? 1. GYNECOLOGIST 2. PHYSICIAN-GENERAL PRACTITIONER 3. NURSE/MIDWIFE 4. SOMEBODY WHO USES CONTRACEPTION 5. FRIEND 6. HUSBAND/PARTNER 7. MOTHER 8. RELATIVE 9. MASS-MEDIA 20. OTHER: ____________________________ 88. DON'T KNOW BOX 7-III IF RESPONDENT IS 15-24 YEARS OF AGE CONTINUE; IF SHE IS 25-44 YEARS GO TO SECTION VIII 716. Have you ever talked to a partner about him using a condom? 1. YES 2. NO 3. NEVER HAD A PARTNER—> GO TO Q719 8. DON'T REMEMBER 717. If your partner/husband would want to use a condom when having sex with you, would you feel: (READ A-F) AGREE DISAGREE DK A. Embarrassed? . 1 2 8 B. Angry?. 1 2 8 C. Safe from getting pregnant? . 1 2 8 D. Safe from getting HIV? . 1 2 8 E. Like you had done something wrong? . 1 2 8 F. Safe from getting STD? . 1 2 8 332 719. Please indicate whether you agree or disagree with the following statements about condoms. AGREE DISAGREE DK A. Condoms diminish sexual enjoyment 1 2 8 B. Condoms are messy to use 1 2 8 C. Condoms requires one's partner to have self control 1 2 8 D. Same condoms can be used more than once 1 2 8 E. People who use condoms sleep around a lot 1 2 8 F. It is embarrassing to buy condoms in a pharmacy or store 1 2 8 G. It is embarrassing to ask for condoms in FP clinics 1 2 8 H. Most women don't like to use condoms 1 2 8 I. Most men don't like to use condoms 1 2 8 J. Using condoms with anew partner is a good idea 1 2 8 K. Using condoms is not necessary if you know your partner 1 2 8 L. Women should ask their partners to use condoms 1 2 8 M. It is easy to discuss using a condom with a prospective partner 1 2 8 719. Now I am going to read you a series of statements. After I read each statement, please tell me whether you agree with the statement or disagree with it: (READ AG) AGREE DISAGREE DK A. It's not always wise for me to plan too far ahead because many things turn out to be a matter of good or bad luck. 1 2 8 B. I have often found that what is going to happen will happen, whether I want it to or not. 1 2 8 C. My life is chiefly controlled by people with more power then me. 1 2 8 D. In order to get what I want, 1 have to conform to the wishes of others. 1 2 8 E. What others in the family want should always come first before what I want. 1 2 8 F. I can generally determine what will happen in my own life. 1 2 8 G. When I get what I want, it's usually because I've worked hard for it. 1 2 8 333 VIII. SOCIOECONOMIC CHARACTERISTICS 800. Please tell me whether this household or any member of it has the following items: (READ A-H): YES NO A. Flush Toilet 1 2 B. Central heating 1 2 C. Refrigerator 1 2 D. TV 1 2 E. Automobile 1 2 F. VCR 1 2 G. Telephone 1 2 H. Vacation home (villa) 1 2 I. Vegetable garden/orchid/vineyard 1 2 801. How many rooms does this house/flat have (not including bathrooms and kitchen): ____ ROOMS 802. Which of these best describes this house/flat? (READ 1-4) 1. Own home/apartment 2. Rental, from private owner 3. Rental, state owned 4. Living with other family/relatives 803. What is your ethnic background? 1. MOLDOVAN 2. RUSSIAN 3. GYPSY 4. UCRA1NIAN 5. GAGAUZAN 7. OTHER (SPECIFY): …………………………………._ 9 REFUSED/NOT STATED 804. What language does your family speak? 1. .MOLDOVAN 2. RUSSIAN 3. MOLDOVAN+RUSSIAN 4. UCRAINIAN 7. OTHER (SPECIFY): …………………………………. _ 805. What is your religion? 1 ORTHODOX 2 CATHOLIC 3. BAPTIST 4. PENTECOSTAL 5. EVANGHELICAL 6. OTHER PROTESTANT 7. OTHER (SPECIFY): …………………………………. __ 8. NO RELIGION ------------>GO TO Q900 9. UNDECLARED—>GO TO Q900 806. About how often do you usually attend religious services? (READ 1-5) 1 At least once a week 2 At least once a month, but less than once a week 3 Less than once a month 4 Only on holidays 5 Never 334 IX-A. KNOWLEDGE OF AIDS 900. The next questions refer to sexually transmitted diseases. Please tell me if you have ever heard about: (READ AG) YES NO DK A. Syphilis . 1 2 8 B. Gonorrhea . 1 2 8 C. Trichomoniasis . 1 2 8 D. Genital Warts (Condylomas). 1 2 8 E. Genital yeast infection. 1 2 8 F. Genital herpes . 1 2 8 G. HIV infection (AIDS). 1 2 8 IF THEY HAVE NEVER HEARD OF HIV/AIDS (Q900G = 2 OR = 8), GO TO Q908 901. In general, what has been your most important source of information about AIDS or HIV? (Where or from whom have you learned the most about AIDS?) 1. TEACHER 2. FAMILY 3. FRIENDS 4. CO-WORKERS 5. DOCTOR/NURSE 6. FAMILY PLANNING CLINIC 7. SCHOOL 8. TV 9. RADIO 10. NEWSPAPERS, MAGAZINES, BOOKS, BROCHURES 20. OTHER ………………. 88. DK 902. Do you think a person can be infected with the AIDS virus and not have any clinical signs of the disease? 1. YES 2. NO 8. DON'T KNOW 903. Do you believe a person can become infected with AIDS in the following ways? (READ A-L) YES NO DK A. Receiving a blood transfusion.1 2 8 B. Using public bathrooms .1 2 8 C. Kissing on the mouth .1 2 8 D. Having heterosexual relations.1 2 8 E. Men having homosexual relations .1 2 8 F. Shaking hands .1 2 8 G. Donating blood .1 2 8 H. Using a non-sterile syringe/needle .1 2 8 I. Mosquito bites .1 2 8 J. Using objects of a person with AIDS .1 2 8 K. Getting a manicure, pedicure or haircut .1 2 8 L. Having medical or dental treatment .1 2 8 335 904. Do you think the following persons generally have no risk, a low risk, or a high risk of getting AIDS? NO LOW HIGH RISK RISK RISK DEPENDS DK A. Married woman 1 2 3 4 8 B. Married man 1 2 3 4 8 C. Homosexual man 1 2 3 4 8 D. Homosexual woman 1 2 3 4 8 E. Prostitute 1 2 3 4 8 F. Intravenous drug user 1 2 3 4 8 G. Unmarried sexually active woman 1 2 3 4 8 H. Unmarried sexually active man 1 2 3 4 8 905. What can a person do to reduce the risk of getting AIDS? SPONTANEOUS PROBED YES NO YES NO DK A. USE CONDOMS . 1 2 3 4 8 B. AVOID RELATIONS WITH PROSTITUTES . 1 2 3 4 8 C. AVOID INJECTIONS. 1 2 3 4 8 D. HAVE ONLY ONE SEXUAL PARTNER. 1 2 3 4 8 E. ASK PARTNER TO HAVE BLOOD TESTED FOR AIDS . . 1 2 3 4 8 F. DO NOT HAVE CASUAL SEXUAL RELATIONS. 1 2 3 4 8 G. STERILIZE NEEDLES . 1 2 3 4 8 H. AVOID RELATIONS WITH BISEXUALS . 1 2 3 4 8 I. OTHER___________ . 1 2 3 4 8 906. Do you think that you have any risk of getting AIDS? 1 YES 2 NO ---------------- >GO TO Q908 8 DON'T KNOW-—>GO TO Q908 907. Would you say that you have a low risk or a high risk? 1 LOW RISK 2 HIGH RISK 8 DON'T KNOW 336 IX-B VIOLENCE 908. This next set of questions is about violence and physical abuse that may have happened between you and a partner or ex-partner. When we say a partner, we mean a husband, ex-husband, as well as any other person you have been living with, without being married. Did a partner or ex-partner ever insult you or swear at you, threatened to hit you, push, shove, or slap you, threaten you with a knife or other weapon, or actually hit you? 1. YES 2 NO------------------------------>GO TO Q916 3. NEVER HAD A PARTNER — ->GO TO Q916 8. DO NOT REMEMBER.>GO TO Q916 909. Please tell me if you have ever been physically abused, by a partner or ex-partner in one of the following ways (READ A-F): 910. When was the last time when (A-F) happened to you? 911. During the last year, how many times did (A-F) happen to you? A. Insult you, or swear at you? 1 YES—> Q910 2 NO—> Q909_ B 8 DK—> Q909_ B 9 REF—> Q909_ B 1. WITHIN THE LAST YEAR->911 2. 1-3 YEARS AGO----------> Q909 B 3. 4-5 YEARS.AGO----------> Q909 B 4. 5 YEARS AGO OR MORE-> Q909 B 8. DON'T REMEMBER----------> Q909^B 1. 1-2 TIMES 2. 3-5 TIMES 3. 6-10 TIMES 4. 11-20 TIMES 5. MORE THAN 20 TIMES 8. DON'T REMEMBER B. Threaten to hit you or throw something at You ? 1 YES—> Q910 2 NO—> Q909_ C 8 DK—> Q909_ C 9 REF—> Q909 _C 1. WITHIN THE LAST YEAR->911 2. 1-3 YEARS AGO----------> Q909_ C 3. 4-5 YEARS AGO----------> Q909_ C 4. 5 YEARS AGO OR MORE-> Q909_ C 8. DON'T REMEMBER ---------> Q909_ C 1. 1-2 TIMES 2. 3-5 TIMES 3. 6-10 TIMES 4. 11-20 TIMES 5. MORE THAN 20 TIMES 8. DON'T REMEMBER C. Push, shove, or slap you ? 1 YES—> Q910 2 NO—> Q909_ D 8 DK.—> Q909_ D 9 REF--> Q909_ D 1. WITHIN THE LAST YEAR->911 2. 1-3 YEARS AGO----------> Q909_ D 3 4-5 YEARS AGO----------> Q909_ D 4 5 YEARS AGO OR MORE-> Q909_ D 8. DON'T REMEMBER ---------> Q909_ D 1. 1-2 TIMES 2. 3-5 TIMES 3. 6-10 TIMES 4. 11-20 TIMES 5. MORE THAN 20 TIMES 8. DON'T REMEMBER D. Kick or hit you with a fist or with something? 1 YES—> Q910 2 NO—> Q909_ E 8 DK—> Q909_ E 9 REF—> Q909_ E 1. WITHIN THE LAST YEAR->911 2. 1-3 YEARS AGO----------> Q909_ E 3. 4-5 YEARS AGO----------> Q909_ E 4 5 YEARS AGO OR MORE-> Q909_ E 8. DON'T REMEMBER ---------> Q909_ E 1. 1-2 TIMES 2. 3-5 TIMES 3. 6-10 TIMES 4. 11-20 TIMES 5. MORE THAN 20 TIMES 8. DON'T REMEMBER E. Threaten you with a knife or othe weapon? 1 YES—> Q910 2 NO—> Q909_ F 8 DK—> Q909 _F 9 REF—>Q909_ F 1. WITHIN THE LAST YEAR-> 911 2. 1-3 YEARS AGO----------> Q909_ F 3. 4-5 YEARS AGO----------> Q909_ F 4 5 YEARS AGO OR MORE-> Q909_ F 8 DON'T REMEMBER ---------> Q909_F 1. 1-2 TIMES 2. 3-5 TIMES 3. 6-10 TIMES 4. 11-20 TIMES 5. MORE Tl IAN 20 TIMES 8. DON'T REMEMBER F. Beat you up? 1 YES—>Q910 2 NO—> BOX 9-1 8 DK—> BOX 9-1 9 REF—> BOX 9-1 1. WITHIN THE LAST YEAR->911 2. 1-3 YEARS AGO---------->BOX 9-1 3 4-5 YEARS AGO---------> BOX9-l 4 5 YEARS AGO OR MORE-> BOX 9-1 8. DON'T REMEMBER ------- >BOX 9-1 1 1-2 TIMES 2. 3-5 TIMES 3. 6-10 TIMES 4. 11-20 TIMES 5. MORE THAN 20 TIMES 8. DON'T REMEMBER BOX 9-1 IF ANY OF THE INCIDENTS C-F TOOK PLACE DURING THE LAST YEAR (ANY Q910_C-Q910_F=1), CONTINUE; ELSE GO TO Q916 337 912. In the past 12 months, did you have any swelling, bruises, cuts, or other physical injuries as a result of this/these incident(s)? 1. YES 2. NO-------------------------->GO TO Q915 8. DON'T REMEMBER ------>GO TO Q915 913. Did you see a doctor, or other medical care provider for medical treatment of these injuries? 1. YES 2. NO ------------------------->GO TO Q915 8. DON'T REMEMBER ------>GO TO Q915 914. Did this(these) injury(ies) require hospitalization? 1. YES 2. NO 8. DON'T REMEMBER 915. Did you talk about this(these) incidents with (READ 1-5)? YES NO 1. Police 1 2 2. Family member 1 2 3. Friend 1 2 4. Health provider/Social Worker 1 2 5. Psychologist ______________ 1 2 7.0Other(Specifiy) ______________ 1 2 916. At any time in your life, have you ever been forced by a man to have sexual intercourse against your will? (For this question, sexual intercourse includes vaginal, anal or oral penetration) 1. YES 2. NO-------------------- >END OF INTERVIEW 8. DON'T REMEMBER—>END OF INTERVIEW 917. How old were you the first time you were forced by a man to have sexual intercourse against your will? ______ AGE 88. DON'T REMEMBER 918. At that time, what was your relationship with the person(s) who forced you to have sexual intercourse? 1. STRANGER 2. ACQUAINTANCE 3. FRIEND 4. DATE 5. BOYFRIEND 6. HUSBAND OR PARTNER 7. EX-HUSBAND OR EX-PARTNER 8. FATHER OR STEP-FATHER 9. OTHER RELATIVE (SPECIFY…………………….) 77. OTHER (SPECIFY …………………………) 88. DON'T REMEMBER 99. REF END OF INTERVIEW TIME INTERVIEW ENDED _________: _____ 338 Cover Reproductive Health Survey Moldova 1997 Final Report CONTENTS Preface Acknowledgments Executive Summary CHAPTER I: INTRODUCTION 1.1 Background 1.2 Objectives of the Survey Tables Table 1-1 CHAPTER II: METHODOLOGY 2.1 Organizational Structure 2.2 Questionnaire Content 2.3 Survey Design Tables Table 2.1 Table 2.2 Table 2.3 CHAPTER III: CHARACTERISTICS OF THE SAMPLE 3.1 Characteristics of the Households 3.2 Characteristics of the Eligible Women 3.3 Radio Listening and Television Viewing Habits Tables Table 3.1.1 Table 3.1.2 Table 3.2.1 Table 3.2.2 Table 3.2.3 Table 3.2.4 Table 3.2.5 Table 3.3.1 Table 3.3.2 Table 3.3.3 Table 3.3.4 Figures Figure 3.1.1 Figure 3.1.2 CHAPTER IV: FERTILITY AND PREGNANCY EXPERIENCE 4.1 Fertility Levels and Differentials 4.2 Induced Abortion Levels and Differentials 4.3 Nuptiality 4.4 Recent Sexual Activity 4.5 Planning Status of the Last Pregnancy 4.6 Pregnancy Outcomes 4.7 Abortion Services 4.8 Reasons for Abortion 4.9 Abortion Complications 4.10 Future Fertility Preferences Tables Table 4.1.1 Table 4.1.2 Table 4.1.3 Table 4.2.1 Table 4.2.2 Table 4.2.3 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7.1 Table 4.7.2 Table 4.7.3 Table 4.7.4 Table 4.8 Table 4.9.1 Table 4.9.2 Table 4.10 Figures Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4.1 Figure 4.4.2 Figure 4.5 Figure 4.6 Figure 4.7.1 Figure 4.7.2 Figure 4.8 Figure 4.10.1 Figure 4.10.2 CHAPTER V: PREGNANCY, DELIVERY, AND MATERNAL HEALTH 5.1 Prenatal Care 5.2 Intrapartum Care 5.3 Postnatal Care 5.4 Breastfeeding 5.5 Smoking and Drinking During Pregnancy 5.6 Pregnancy and Postpartum Complications Tables Table 5.1.1 Table 5.1.2 Table 5.1.3 Table 5.1.4 Table 5.1.5 Table 5.2.1 Table 5.2.2 Table 5.2.3 Table 5.2.4 Table 5.2.5 Table 5.3 Table 5.4.1 Table 5.4.2 Table 5.4.3 Table 5.4.4 Table 5.5 Table 5.6.1 Table 5.6.2 Table 5.6.3 Table 5.6.4 Figures Figure 5.1.1 Figure 5.1.2 Figure 5.2 Figure 5.4.1 Figure 5.4.2 CHAPTER VI. KNOWLEDGE OF CONTRACEPTION 6.1 Contraceptive Awareness and Knowledge of Use 6.2 Knowledge About Contraceptive Effectiveness 6.3 Knowledge about Condoms' Effectiveness in Preventing STDs 6.4 Knowledge About Advantages and Disadvantages of Using the Pill and IUD Tables Table 6.1.1 Table 6.1.2 Table 6.1.3 Table 6.1.4 Table 6.2.1 Table 6.2.2 Table 6.3 Table 6.4.1 Table 6.4.2 Table 6.4.3 Table 6.4.4 Figures Figure 6.1 Figure 6.2 Figure 6.4.1 Figure 6.4.2 CHAPTER VII. ATTITUDES AND OPINIONS ABOUT CONTRACEPTION 7.1 Opinions About the Best Method to Prevent Pregnancy 7.2 Opinions on Safety of Birth Prevention Methods 7.3 Opinions on the Best Source of Information About ContraceptionThe Tables Table 7.1 Table 7.2.1 Table 7.2.2 Table 7.3 Figures Figure 7.1 Figure 7.2 Figure 7.3 CHAPTER VIII. CURRENT AND PAST CONTRACEPTIVE USE 8.1 Current Contraceptive Prevalence 8.2 Source of Contraception 8.3 Preference for Other Methods and Dissatisfaction with the Current Method 8.4 Users of Non-Supplied Methods 8.5 Recent Trends in Contraceptive Use 8.6 Contraceptive Failure and Discontinuation 8.7 Discussions About Contraception with Current Partner 8.8 Reasons for Not Using Contraception 8.9 Potential Demand and Unmet Need for Contraception 8.10 Contraceptive Sterilization Tables Table 8.1.1 Table 8.1.2 Table 8.1.3 Table 8.1.4 Table 8.1.5 Table 8.1.6 Table 8.2 Table 8.3.1 Table 8.3.2 Table 8.3.3 Table 8.4.1 Table 8.4.2 Table 8.5 Table 8.6.1 Table 8.6.2 Table 8.7 Table 8.8 Table 8.9.1 Table 8.9.2 Table 8.10 Figures Figure 8.1.1 Figure 8.1.2 Figure 8.1.3 Figure 8.3 Figure 8.5.1 Figure 8.5.2 Figure 8.9 Figure 8.10 CHAPTER IX. CONTRACEPTIVE COUNSELING 9.1 Communication with Family Planning ProvidersWomen 9.2 Satisfaction with Counseling Services 9.3 Post-abortion and Postnatal Counseling Tables Table 9.1 Table 9.2 Table 9.3 Figures Figure 9.1 CHAPTER X. REPRODUCTIVE HEALTH ATTITUDES 10.1 Ideal Family Size 10.2 Attitudes Toward Abortion 10.3 Attitudes and Perceptions About Reproductive Norms and Gender Roles Tables Table 10.1 Table 10.2.1 Table 10.2.2 Table 10.2.3 Table 10.2.4 Table 10.3.1 Table 10.3.2 Figures Figure 10.2.1 Figure 10.2.2 CHAPTER XI: SEX EDUCATION 11.1 Opinions about Sex Education In School 11.2 Discussions About Sex Education Topics with Parents 11.3 Sex Education Instruction in School 11.4 Sex Education's Impact on Knowledge About Fertility Issues and Contraception Tables Table 11.1.1 Table 11.1.2 Table 11.1.3 Table 11.2.1 Table 11.2.2 Table 11.3.1 Table 11.3.2 Table 11.3.3 Table 11.4.1 Table 11.4.2 Table 11.4.3 Table 11.5.4 Table 11.5.5 Figures Figure 11.1 Figure 11.2 Figure 11.3.1 Figure 11.3.2 CHAPTER XII: SEXUAL AND CONTRACEPTIVE BEHAVIOR AMONG YOUNG ADULTS 12.1 Sexual Experience 12.2 Current Sexual Activity 12.3 Contraceptive Use at First Sexual Intercourse 12.4 Reasons for Not Using Contraception At the Time of First Sexual Intercourse 12.5 Use of Contraception at Most Recent Sexual Intercourse 12.6 Opinions and Attitudes About Condoms and Condom Use Tables Table 12.1.1 Table 12.1.2 Table 12.1.3 Table 12.2 Table 12.3.1 Table 12.3.2 Table 12.3.3 Table 12.4.1 Table 12.4.2 Table 12.6.1 Table 12.6.2 Table 12.6.3 Figures Figure 12.1.1 Figure 12.1.2 Figure 12.2 Figure 12.3 Figure 12.6 CHAPTER XIII. HEALTH BEHAVIORS 13.1 Cigarette Smoking 13.2 Alcohol Use 13.3 Prevalence of Routine Gynecologic Visits Among Sexually Experienced Women 13.4 Breast Self-Exam 13.5 Cervical Cancer Screening 13.6 Prevalence of Selected Health Problems Among Women of Reproductive Age Tables Table 13.1 Table 13.2 Table 13.3 Table 13.4 Table 13.5 Table 13.6 Figures Figures 13.1 Figures 13.3 Figures 13.5 Figures 13.6 CHAPTER XIV PHYSICAL AND SEXUAL ABUSE 14.1 History of Verbal and Physical Abuse by a Partner or Ex-Partner 14.2 Physical Abuse During the Past 12 Months by a Partner or Ex-PartnerIn 14.3 Prevalence of Forced Sexual Intercourse Tables Table 14.1.1 Table 14.2.1 Table 14.2.2 Table 14.2.3 Table 14.3 Figures Figure 14.1.1 Figure 14.1.2 Figure 14.1.3 Figure 14.2 Figure 14.3.1 Figure 14.3.2 CHAPTER XV: KNOWLEDGE OF AIDS TRANSMISSION AND PREVENTION 15.1 Knowledge of AIDS and Other STDs 15.2 Source of Information About HIV/AIDS 15.3 Knowledge About HIV/AIDS Transmission 15.4 Knowledge About HIV/AIDS Prevention 15.5 Beliefs About Risk of HIV/AIDS Among Selected Groups and Self-Perceived Risk of HIV/AIDS Tables Table 15.1.1 Table 15.1.2 Table 15.2 Table 15.3.1 Table 15.3.2 Table 15.4.1 Table 15.4.2 Table 15.5.1 Table 15.5.2 Figures Figure 15.1 Figure 15.2 Figure 15.3 Figure 15.4 Figure 12.5 REFERENCES APPENDIX A: SAMPLING ERROR ESTIMATES Table A.1 APPENDIX B INSTITUTIONAL PARTICIPATION PERSONS INVOLVED IN THE 1997 MOLDOVAN REPRODUCTIVE HEALTH SURVEY OPERATION AND SUPERVISION FIELD INVESTIGATORS QUESTIONNAIRE 1997 MOLDOVA REPRODUCTIVE HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE 1997 MOLDOVA REPRODUCTIVE HEALTH SURVEYINDIVIDUAL QUESTIONNAIRE I. BACKGROUND CHARACTERISTICS II. SEX EDUCATION III. FERTILITY/ PREGNANCY IV. FAMILY PLANNING KNOWLEDGE/ SEXUAL EXPERIENCE V. CURRENT AND PAST CONTRACEPTIVE USE VI. WOMEN'S HEALTH VII REPRODUCTIVE HEALTH KNOWLEDGE/ATTITUDES VIII. SOCIOECONOMIC CHARACTERISTICS IX-A. KNOWLEDGE OF AIDS IX-B VIOLENCE

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