Reproductive Health Survey 1993 Final Report

Publication date: 1995

ROMANIA REPRODUCTIVE HEALTH SURVEY 1993 FINAL REPORT Institute for Mother and Child Health Care Bucharest, Romania Centers for Disease Control and Prevention Atlanta, Georgia USA March 1995 PREFACE During the previous regime (1966-1989) Romania was the setting of a distinct pronatalist policy and extreme measures were taken to enforce compliance with the law. The restrictive law, which permitted abortion for only very limited medical and social reasons and prohibited importation and distribution of modern contraceptives, had a direct impact on the maternal mortality rate, which rapidly reached exorbitant levels, on women's health and on reproductive behaviors of the society. After abortion became legal, clinics were inundated by women seeking abortions, whereas the newly created national family planning program had little impact on averting unwanted fertility. Induced abortion was often regarded as the only method of family planning. Consequently, the legally induced abortion rate had reached one of the highest level in the world. Information about contraceptive use is not routinely collected and little is known about knowledge, attitudes, and perceived effectiveness of contraceptive methods at the national or regional level. This information is particularly useful in assisting policy makers and health planners to assess health services needs, to identify reproductive health behaviors associated with poor health outcomes, and to design better targeted programs for meeting the needs of key population subgroups. A population-based survey of women of childbearing age with a national representative sample was considered to be the best and most timely way to collect information on fertility, planning status of pregnancies, family planning, health behaviors and use of women's health services, contraception knowledge and attitudes, knowledge about AIDS transmission and prevention, and other reproductive health issues. This study represents not only a valuable source of up-to-date information to evaluate population, health and family planning programs but also a baseline for future studies. With assistance from the Division of Reproductive Health of Centers for Disease Control and Prevention (DRH/CDC), the successful completion of the survey can be a model not only for other national studies, but also for similar surveys in Central and Eastern Europe. We would like to acknowledge all the local and international organizations and persons who contributed to various phases of the survey, who provided financial support and technical assistance and who devoted personnel and equipment. In the name of the steering committee, I would like to thank to all the survey participants and supporters, to all who have dedicated their time, ideas and efforts and to the women respondents whose cooperation made this survey possible. Alin Stanescu M.D. Survey Director Editors Note We would like to acknowledge all the organizations and persons who contributed to the various phases of the Romanian Reproductive Health Survey (RRHS). They are are listed on the following page. The survey was conducted by the Romanian Institute for Mother and Child Care (IOMC), Romanian Ministry of Health (MOH), with technical assistance from the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (DRH/CDC), Atlanta, Georgia, USA. The funding for the RRHS was provided by the United States Agency for International Development (USAID) through the Centre for Development and Population Activities (CEDPA), the United Nations Population Fund (UNFPA), through the local UNDP office, the Romanian Ministry of Health, through the Academy of Medical Sciences, and the United Nations Children's Fund (UNICEF). The IOMC wishes to place on record its sincere thanks to all those organizations which participated in the planning of the Romanian Reproductive Health Survey, the development of the questionnaire and the review of the various modules. Also, to the CDC team which provided technical assistance in the areas of survey design and sampling, questionnaire development and training, data processing and report preparation. Finally, to the almost 5,000 women who gave up their time to answer so many questions, we owe a debt of gratitude for this information, which we are sure will be useful in enhancing the status of women's health in Romania. INSTITUTIONAL PARTICIPATION Ministry of Health Alin Stanescu, M.D. Academy of Medical Sciences Mihai Zamfirescu, M.D. Institute of Mother and Child Care Gabriel Banceanu, M.D. (Polizu) (IOMC) Adrian Georgescu, M.D. (Irza) National Health Statistics Center Petru Muresan, M.D. (NHSC) Dan D. Farcas, D. Sc. Vasile Scortan Institute for Public Health and Research Mihai Horga, M.D. (Tirgu-Mures) National Commission of Statistics Ion Grigorgoiu Radu Halus Vasile Ghetsau, D.Sc. Association for Public Health and Cristian Havriliuc, M.D. Management (APHM) UNDP (Bucharest) Bernard H. Fery Carlos Benedito Prieto KatyJ. Shroff, M.B., B.S. UNFPA (New York) Sietske Steneker UNICEF (Bucharest) Rosemary McCreery Maie Ayoub von Kohl AID, EUR/DR/HR Kathleen S. McDonald, M. Sc. (Washington D.C.) Julia Terry Paula Bryan, M.P.H. USAID/Bucharest Richard J. Hough Mary Ann Micka, M.D., M.P.H. Rodica Furnica CEDPA Roseanne Murphy (Washington D.C.) Daniela Draghici (Bucharest) CDC (Atlanta) Leo Morris, Ph.D., M.P.H. Fiorina Serbanescu, M.D., M.P.H. Douglas A.(Skip) Cook, M.B.I.S. Paul Stupp Ph.D. Jay Friedman M.A. STEERING COMMITTEE (OPERATION AND SUPERVISION) Alin Stanescu, M.D., Project Director, IOMC/MOH Leo Morris, Ph.D., M.P.H., Project Director, CDC Fiorina Serbanescu, M.D., M.P.H., Project Manager, CDC Magdalena Petrache, M.D., Assistant Project Director, IOMC (Polizu) Mihai Horga, M.D., Assistat Project Manager, IPH/Tg-Mures Ecatarina Stativa, Field Coordinator, IOMC Luminita Marcu, Administrative Assistant, MOH Ion Nistor, Chief Accountant, APHM Bogdan Giurginca, Accountant, APHM Stelian Popa, Data Entry Coordinator, NHSC/MOH FIELD INVESTIGATORS Ecaterina Stativa, Sociologist, Field Coordinator Team No.l Lucia Branga (NHSC). Team supervisor Carmen Baran, Student (Institute for Social Work) Corina Dumitru, Student (Institute for Social Work) Lucia Roznatovschi (NHSC) Ioana Tasca, Student (Institute for Social Work) Elena Malceolu, Sociologist (NHSC) Team No.2 Constantin Stancu. Statistician (NHSC). Team Supervisor Carmen Goldis, M.D., IOMC/Irza Florentina Moldovan, M.D., IOMC/Irza Ecaterina Rosca (NHSC) Ecaterina Scortan (NHSC) Team No.3 Denisa Ionete M.D., IOMC/Polizu. Team Supervisor Georgiana Antohi, M.D., Irza Hsp. Gabriela Coman, Student (Sociology) Mioara Platon (NHSC) Anca Popa, Teacher Team No.4 Carmen Cruceanu, M.D.,Polizu Hsp.,Team Supervisor Dana Costin, Student (Institute for Social Work) Madalina Gheorghe, Student, (Institute for Social Work) Mioara Stefan (NHSC) Lidia Voinoiu, M.D., Irza Hsp. Ileana Vlasceanu Team No.5 Eva Berecki, M.D Adina Ciotea, Teacher Irina Stefan, Teacher Monica Mitran, Student Maria Ionela Blaj, Student CONTENTS Page PREFACE EDITORS NOTE EXECUTIVE SUMMARY Fiorina Serbanescu, Leo Morris, Alin Stanescu, Carmen Cruceanu I. INTRODUCTION. 1 Fiorina Serbanescu, Leo Morris 1.1 Background . 1 1.2 Objectives of the Survey . 3 II. METHODOLOGY. 5 Leo Morris, Fiorina Serbanescu 2.1 Organizational Structure . 5 2.2 Questionnaire Content . 5 2.3 Sampling Design . 7 III. CHARACTERISTICS OF THE SAMPLE . 11 Fiorina Serbanescu, Leo Morris 3.1 Characteristics of the Households . 11 3.2 Characteristics of the Respondents . 14 IV. FERTILITY. 19 Fiorina Serbanescu, Paul Stupp, Leo Morris 4.1 Fertility Levels and Trends. 19 4.2 Fertility Differentials . 24 4.3 Nuptiality . 25 4.4. Age at First Intercourse, Union and Birth . 27 4.5 Recent Sexual Activity . 31 4.6 Planning Status of the Last Pregnancy . 34 4.7 Changes in Planning Status of Pregnancy . 36 4.8 Wanted and Unwanted Pregnancy Rates. 38 4.9 Desire for Additional Children . 40 V. INDUCED ABORTION .45 Fiorina Serbanescu, Paul Stupp 5.1 Induced Abortion Levels and Trends. 46 5.2 Induced Abortion Differentials. 51 5.3 Reasons for Abortion. 53 5.4 Provision of Abortion Services . 55 5.5 Induced Abortion Complications . 56 5.6 Abortion Mortality . 58 5.7 Abortion and Contraception . 59 VI. CONTRACEPTION.61 Fiorina Serbanescu, Leo Morris 6.1 Knowledge of Family Planning Methods and Source of Methods . 61 6.2 Current Contraceptive Prevalence and Recent Trends . 69 6.3 Source of Contraceptive Methods and Their Cost. 77 6.4 Reasons for Not Using Contraception. 79 6.5 Nonusers and Traditional Method Users . 81 6.6 Contraceptive Failure and Discontinuation Rates . 83 6.7 Intention To Use Contraception and Induced Abortion in the Future .87 VII. WOMEN IN NEED OF FAMILY PLANNING SERVICES .91 Fiorina Serbanescu, Carmen Cruceanu VIII. ATTITUDES AND OPINIONS ABOUT ABORTION AND CONTRACEPTION Jay Friedman, Fiorina Serbanescu, Leo Morris 8.1 Ideal Family Size .97 8.2 Knowledge of the Menstrual Cycle . 100 8.3 Attitudes About Abortion . 100 8.4 Opinions About Modern Contraceptives . 105 8.5 Information About Contraceptive Methods. 111 8.6 Attitudes Toward Family and Reproductive Roles . 114 IX. MATERNAL CARE . 117 Fiorina Serbanescu, Magda Petrache, Leo Morris 9.1 Prenatal Care. 117 9.2 Maternal Morbidity During Pregnancy . 126 9.3 Smoking During Pregnancy . 127 9.4 Employment and Pregnancy . 130 X. HEALTH BEHAVIORS . 133 Fiorina Serbanescu, Magda Petrache 10.1 Cigarette Smoking. 133 10.2 Cervical Cancer Screening . 136 10.3 Gynecological Visits . 138 10.4 Breast Self-Examination. 140 XI. YOUNG ADULTS . 145 Ecaterina Stativa, Leo Morris, Jay Friedman 11.1 Sexual Experience. 146 11.2 Contraceptive Use. 151 11.3 Premarital Pregnancy. 156 11.4 Discussions with Mother About Contraception . 158 XII. KNOWLEDGE OF AIDS TRANSMISSION AND PREVENTION . 161 Mihai Horga, Leo Morris, Fiorina Serbanescu REFERENCES STANDARD ERRORS RRHS QUESTIONNAIRE EXECUTIVE SUMMARY Introduction The 1993 Romanian Reproductive Health Survey (RRHS-93) is a household-based survey designed to collect information from a representative sample of women of reproductive age throughout Romania. This nationwide probability survey of reproductive health is the first to be carried out in Romania since 1978. During the previous regime, contraceptives and sex education were generally unavailable and importation and sale of contraceptives was forbidden; traditional contraceptive methods, with their high failure rates, were almost the only means to avoid unintended pregnancies. In the absence of modern contraception, illegal abortions, most of them self-induced or induced by lay persons, were widely used to avert unwanted births. Although the extent of the prevalence of illegal abortions was impossible to assess, the dramatic effect on women's health was obvious to government officials but concealed from the public for many years. The true scope of the impact this policy had on reproductive health came to worldwide attention only after the December 1989 revolution and the change of government. During the last decade (1979-1989), Romania had the highest maternal mortality rate in Europe, a rate ten times higher than that of any other European country, and most of these maternal deaths were abortion-related (Stephenson et al., 1992). The magnitude of abortion complications is difficult to quantify but unofficial estimates suggest that nearly 20% of the 4.9 million women of reproductive age are thought to have impaired fertility (UNFPA 1990). The high number of unwanted pregnancies resulting in children abandoned in overcrowded orphanages by families who had been too frightened to attempt an illegal abortion, but who were too poor to afford to raise their child, was another shocking disclosure. After revoking the restrictive law on abortion and contraception at the end of December 1989, the availability of safe abortion resulted in a drastic decline in me maternal mortality rate and improved women's health and their reproductive rights. However, the health planners who strived to design a family planning program were confronted with a difficult mission: to formulate and implement strategies aimed at improving family planning practices in a climate of economic and political changes and resistance to modern contraception by both the public and the health care providers. Also, insufficient infrastructure, absence of family planning logistics and managerial skills, and the shortage or uneven distribution of the contraceptive supplies were other critical factors that have diminished the impact of the newly founded program. The principal goal of the RRHS-93 was to obtain data on reproductive behaviors and other selected women's health issues in order to assist policy makers and program managers in assessing health needs and providing comprehensive health care services. Methodology The survey used a stratified sample design with independent samples for Bucharest, the capital city, and the interior which is divided into 40 administrative districts called judets. Bucharest, together with the surrounding Agricultural Sector of Ilfov, is the equivalent of a judet. The 1992 census was used as the sampling frame (Comisia Nationala Pentru Statistica, 1992). Since the numbers of urban and rural households in the Interior were roughly equal, the Interior sample was designed to be self-weighting. Based on the percentage of households with at least one woman 15-44 years of age and on a projected response rate of 90%, a sample of 12,387 households was selected from which to obtain complete interviews for approximately 5,000 women. Although it included 11% of the total population, Bucharest was oversampled to represent 22% of the sample and to allow independent estimates. Survey results were weighted to adjust for the oversampling of households in Bucharest and to compensate for randomly selecting only one woman from households with more than one eligible woman. Of the 12,387 households selected, 5,283 included at least one 15- to 44 year-old woman. Of this number, 4,861 were successfully interviewed, for a response rate of 92.0%. Only 1.1% the of selected women refused to be interviewed, while another 6.1% could not be located. Response rates were slightly better in Bucharest and other urban areas (93%) than in rural areas (89%). Interviews, conducted at the respondents' homes by trained female interviewers, generally lasted 30 to 50 minutes. The age distribution, marital status distribution and fertility experience of the RRHS sample closely reflected that of the female population as a whole (Comisia Nationala Pentru Statistica, 1993A). The RRHS questionnaire covered a wide range of topics related to reproductive health in Romania: a history of all pregnancies and births (including pregnancies ending in abortion) and the planning status of the pregnancies; family planning (knowledge and history of use of contraceptive methods, reasons for use of less effective methods of contraception, pregnancy intentions, and fecundity); maternal and child health (health information about the most recent pregnancy and birth and the use of maternal and child health services); young adult reproductive health (information about premarital sexual experience and pregnancy among women 15-24 years old); women's health (health behavior and use of women's health services); reproductive health knowledge and attitudes (especially regarding birth control pills and IUDs); knowledge about AIDs transmission and prevention; and socioeconomic characteristics of women and their husbands or families. The questionnaire also included a monthly calendar of pregnancies, segments of contraceptive use, and reasons for discontinuing use, over a 5-year period beginning in January 1988. Fertility Until recently, Romania was the setting of the most rigorously enforced pronatalist policy. A restrictive law, issued in 1966, reversed the legal status of abortion decreed in 1957 and permitted modern contraceptive use and induced abortion for only very limited medical and social reasons. Although extreme measures were taken to enforce compliance with the law and a new decree issued in 1985 further restricted access to abortion and contraception, the resultant fertility increase in the long term was far below expectations of the government. After an initial surge in fertility in 1967-1968 to 3.6 births per woman, a rate more than twice the 1966 level, the total fertility rate (TFR)* fell to 2.9 in 1970 and continued to decrease slowly to 2.2 in 1980-1984 and stabilized around 2.3 births per woman during the 1985-1989 period. After abortion became legal, the TFR dropped sharply, to below replacement level, from 2.3 live births per woman for 1987-1989 to 1.5 live births for 1990-1993, while the total induced abortion rate (TIAR)** doubled, from 1.7 to 3.4 abortions per woman for the same periods. A similar fertility decline was noted after the previous legalization of abortion in 1957 when the TFR decreased by one third (from 2.8 to 1.8 births per woman) from 1958 to 1966. Almost 70% of the TFR can be attributed to women aged 20-29 in both periods of time, in spite of the considerable decline in fertility rates in the recent years. Fertility trends for women younger than 30 years of age are particularly important in Romania, where, by the age of 30, 91 % of the women have already given birth to their first child and the median age at the first live birth is 22 years. All age-specific fertility rates have sharply declined, except those for women aged 40-44, whose rate was very low in both periods. Although the greatest decrease in fertility occurred among women 30-34 and 35-39 years of age, their low age- specific fertility rates in the most recent period accounted for only 11% and 4%, respectively, of the overall fertility. The highest age specific abortion rates were experienced by women aged 25-29, followed by women aged 30-34 in both periods of time. About a half of the TIAR can be attributed to these women. Although the highest increase in abortions was experienced by women under age 20, their low age specific abortion rate accounted for only 5% of the TIAR. A comparison of age-specific marital fertility rates and marital induced abortion rates for the two periods reveals that marital fertility rates for all age groups were higher than fertility rates for all women and induced abortion rates for married women were higher than those for all women and, by implication, higher than those for unmarried women. These findings are consistent with another survey finding that only 5 % of pregnancies are terminated before the date of first union, and illustrate that abortion is primarily associated with married women in Romania. There was a notable difference in the TFR between urban and rural residents: urban women had almost one child less than did rural women. Also, in the second period, the abortion * The TFR is calculated by accumulating age specific fertility rates for a certain period of time and divided by 5. It is interpreted as the average number of children that a woman would have during her reproductive life, if she would experience the age specific fertility rates that occurred during a specific period of time. ** The TIAR was calculated in the same manner as TFR, except that induced abortion instead of live births were included in the numerator. Conversely, it represents the lifetime number of abortion a woman would experience if she would be the subject of age specific abortion rates observed during a specific period of time. rate for urban women was 9% higher than the rate for rural women. Education was inversely related to both the fertility rate and the induced abortion rate. The least educated women consistently reported the highest rates of fertility and abortion, and while their TFR dropped by one third, from 3.5 to 2.3, their TIAR more than doubled, reaching almost five lifetime induced abortions per woman after the change in legislation. The more highly educated women had a 28% decline in fertility, and their induced abortion rate doubled. Data on the planning states of all pregnancies in the two periods demonstrate significant changes. More than two thirds of pregnancies were reported either mistimed (wanted at a later time), or unwanted after the change in legislation. The planning status is strongly correlated with pregnancy outcome. For both periods, more than 95% of the women whose pregnancy ended in induced abortion reported their pregnancy to be unintended. It should also be noted that a relatively high proportion of women whose pregnancy ended in miscarriage or stillbirth in the most recent period had reported it as an unwanted conception (22%); this percentage is almost three times that of women with live births who reported an unwanted pregnancy. One can only speculate that some of these outcomes may have been induced abortions reported as spontaneous abortions or stillbirths. Future childbearing desires can influence future fertility levels. Of the women who were currently in union, almost 60% did not want to have any more children, 5% wanted to wait at least 2 years before having a child, and only 10% wanted a child in the near future. Almost 20% thought they could not become pregnant and cited as the main reason either their failure to conceive in the last two years without using contraception, gynecological surgery other than contraceptive sterilization, or partner subfecundity. If we exclude these subfecund women from the denominator, then 73 % did not want to have any more children, and this proportion increased to more than 92% for women with two or more children. Knowledge, Current Use and Source of Contraception Almost all women currently in union (95%) had heard of at least one modern method of contraception, and no significant differences in the level of overall modern contraception awareness by residence and educational level surfaced. However, the level of knowledge of specific modern methods varied. The most widely known modern methods were the condom, the pill, and the IUD (80% or greater awareness), and the least known were injectables, vasectomy, and the use of the diaphragm, known by 16%, 13% and 9%, respectively. Not only was the overall awareness high, but 85 % of women in union knew at least one place where they thought they could obtain a modern method. The knowledge of where to go for a family planning method was affected by residence and education: rural residents and less educated women were less likely to have such information. Overall, the major source of information about any contraceptive method was a friend or acquaintance (45%), followed by mass media (19%), and health care providers (10%). Only 4% of the women said that they first heard about contraception from their mother, and less than 3 % cited a teacher as their first source of information. Although the overall level of family planning awareness was high, for the most widely known contraceptive methods there was a serious gap between awareness of the method and knowledge of where the procedure or product could be obtained; the gap ranged from 9 percentage points for tubal ligation to more than 30 percentage points for the IUD and the condom. At the time of the survey, 57% of women currently in union reported using a contraceptive method. The prevalence was 43% for traditional methods: 35% for couples using withdrawal and 8% for women using the calendar method. Only 14% of women in union were using modern contraceptives, mostly IUD, condom and pill. Less than 2% were contraceptively sterilized and no vasectomies were reported. Contraceptive prevalence is highest in Transylvania (67%), highest among women 25-34 years of age (66%-69%) and positively correlated with education level. The percentage of all contracepting women who use contraception and who use modern methods is higher in urban areas, in Bucharest and Transylvania, among the highly educated women, and among those with fewer children. However, in no group does the prevalence rate for using modern methods surpass 24%. Pharmacies, which provide 38% of current users, are the most important source of modern contraceptives; the next most important source, providing for 31% of users, is the governmental sector through "contraceptive cabinets" set up mainly in hospitals but also in polyclinics and dispensaries. Another important source, which provides 17% of users, is the "black market". The nongovernmental sector supplies only 5% of users. Contraceptive use is much lower among previously married women (14%) and almost negligible among never married women (5%), since they are much less likely to report being sexually active. As a result, the overall prevalence for all women aged 15-44 is about 41 %. The contraceptive prevalence for all women before and after the change in legislation increased by 20% but 70% of the increase is the result of higher prevalence of traditional methods. The increase in modern contraceptive use is almost entirely due to increase usage of IUDs-from 0.6% to 1.7%-and condoms-from 1.8% to 2.7%-whereas the prevalence of other methods do not show any change (i.e the pill prevalence of 2.3% remains unchanged). Additional questions designed to explore attitudes and opinions about modern methods revealed a high level of misinformation and preconceptions. When users of traditional methods were asked how important were several specified reasons for not using a modern method, most women stated that fear of side effects, partner preference, and little knowledge about modern methods influenced their decision to not use a modern method. About one third cited the difficulty of obtaining modern contraceptives or their cost. One fourth acknowledged as an important reason that their physician recommended that they not use a modern method. Almost two thirds of traditional method users believed that their method was equally as effective as or even more effective than the pill or the IUD. Surprisingly, this belief was not affected by education. These findings document the lack of correct information about modern contraceptives and highlight women's trust in the traditional methods historically practiced in Romania. The women's trust in traditional methods is not justified if one considers the high failure rates associated with these methods. Life table analysis of segments of contraceptive use begun since the change in legislation showed that for both withdrawal and the calendar method, 30% of users had a pregnancy within 12 months of initiating use. Three fourths of the 12-month discontinuation rate for these methods is accounted for by method failure. The condom also had a high failure rate of 21%, which accounted for almost half of the reasons for which this method was discontinued. The IUD and the pill failure rates at 12 months are comparable to rates published in the literature. The low prevalence of modern method use contrasts with the high proportion of women in union, throughout all socioeconomic subgroups, who desired to limit their fertility. Most fecund women currently in union, despite their intention to terminate childbearing, use traditional methods, and only 15% of them expressed a desire to use a modern method in the future. Less than 1% expressed an interest in surgical contraception. Those not interested said their most important reason for lack of interest was the fear of side effects (27%), the fear of surgery (17%), or "they never thought about it" (16%). Women in Need of Family Planning Services Nine percent of all women aged 15-44 were estimated to be in need of family planning services, but if the need for more effective contraception among women using traditional, less effective methods is taken into account, the proportion is much higher (39%). These women are fecund, currently sexual active, who did not want to get pregnant and were not pregnant or in postpartum abstinence at the time of the interview, and who were not using any or were using less effective contraceptive methods. If we narrow the definition to women currently in union, more than a half of them are at risk of unintended pregnancies because they are not using effective contraception. This figures translates into more than 1.9 million women in need of any or more effective contraception, 93% of them in union. The proportion of women in need is higher among those living outside Bucharest, those older than age 24, those with low level of education, and those with low or medium socioeconomic status. Reproductive Health Knowledge and Attitudes Respondents were asked what they thought was the ideal number of children for a young family in Romania. The ideal number or mean desired number of children for all women was 2.1 children. When women were asked, at what time during the menstrual cycle is a woman at greatest risk of becoming pregnant, only 54% correctly said that the chance of pregnancy is greatest halfway between menstrual periods. Knowledge of the menstrual cycle was lowest among women who live in rural areas (42%), women under age of 20 (27%), among never married women (37%), among gypsy women (17%), and women with only primary education (37%). Knowledge of the menstrual cycle increased sharply with increased education (from 37% to 84%) and socioeconomic status (from 38% to 72%). Overall, 43% of women said the pill is unsafe for women's health and another 38% did not know whether the pill is safe or not. Fewer than 20% of women believed that the pill is at least somewhat safe. The percentage who felt that the pill is safe was highest for women in Bucharest and women aged 20-34 years. As with the pill, women were generally unaware of the efficacy of the IUD (49%) or underestimated its ability to prevent pregnancy. Only 32% of the respondents said that a woman whose IUD was inserted correctly could be completely or almost sure that she would not become pregnant, while almost half said they do not know. Overall, only 57% of women said they would like to have more information about contraception. This is inversely correlated with age, with more than 75% of women 15-24 years of age reporting a desire for information on this subject and only 38% and 21%, respectively, of women aged 35-39 and 40-44 years. Associated with younger age, 79% of never married women and 73 % of childless women expressed a desire for more information. Almost three-fourths of women surveyed (72%) said that women always have the right to decide about their pregnancies, including abortion. At least two thirds of every segment of population believed that should be no restrictions on abortion. Maternal Health The overall percentage of women receiving any prenatal care is 94% and varies within a narrow range according to maternal characteristics. However, a large proportion of them did not have an adequate number of prenatal visits. Between January 1988 and June 1993, less than a quarter (23%) of mothers had 10 or more visits during their last pregnancy which resulted in a live birth. Almost 20% had only 1-3 visits, 34% 4-6 visits and 18% 7-9 visits. The proportion of women with an inadequate number of visits is higher in rural areas, in the northeast part of the country (Moldavia), among women with less than 12 years of formal education, among the youngest mothers, and among those with low socioeconomic status. Slightly more than a half of mothers (57%) had complied with the norms regarding early initiation of prenatal visits, whereas 34% sought prenatal care in the second trimester and 4% in the third trimester. Only 60-61 % of mothers who sought prenatal care received information about nutrition, the adverse effects of smoking and alcohol abuse, and about rest and physical activity during pregnancy. About 30% of mothers with a live birth since January 1988 experienced an important health problem during their last pregnancy: 20% had been hospitalized and 10% had to spend at least one week in bed for that problem. The median duration of hospitalization was 14 days. Health Behaviors According to the survey data, more than one in five women of childbearing age (22%) is a smoker. An additional 7% have smoked but reported that they quit. Urban residents, are much more likely to currently smoke (p<0.01) than rural residents. Women residing in Bucharest and Transylvania are more likely to currently smoke, whereas women in Moldavia are the least likely to be either current or past smokers (15% and 7% respectively). Women currently in union are twice as likely to smoke as never married women (25% vs. 13%) but previously married women are the most likely to smoke (41 %). Only about a quarter (27%) of the respondents who reported having had sexual relations said that they have ever had a cervical cancer screening test (Pap smear). Even among employed women who, during the previous regime, were supposed to be routinely screened for early detection of pregnancy and gynecologic problems, only 36% said they had ever had a Pap smear. Among those unemployed, the proportion who have ever been screened is much lower (17%). The low prevalence of cervical cancer screening may be partly explained by a general reluctance to undertake routine gynecologic exams. Overall, only 35% of sexually experienced women had gynecologic exams frequent enough (within 3 years) to insure an effective cervical screening program, whereas 44% reported that they have never been routinely examined. Among employed women, only slightly more than one third (36%) said that in fact they have never been routinely examined. Overall, less than a half of respondents have ever heard about breast self-examination and less than one in four have ever performed it. Young Adults Almost half of 15-24 years old women (41%) reported that they have had sexual intercourse (16% of 15-19 years old and 70% of 20-24 years old women). However, by age 24, the majority of women (84%) reported having had sexual relations. Slightly more than a half of those reporting sexual experience had premarital sexual intercourse. There were only small differences in sexual experience among various subgroups studied. However, premarital sexual experience varied greatly: urban residents, less educated women and Hungarian and gypsy young women were more likely to have premarital sexual intercourse. Only 26% of young women with premarital sexual experience reported that they or their partner used contraception at first intercourse and the most prevalent method was withdrawal. Among young women whose first intercourse was marital, even fewer reported using a contraceptive method at first intercourse (15%) but the most prevalent method was also withdrawal. About three-fourths of young women reported that they had ever been pregnant and about 17% of those said they were not married at the time they first became pregnant. Of those who reported premarital pregnancy, 61% said the father was a boyfriend or a friend with most of the reminder being fiances at the time they became pregnant. Almost two thirds eventually married the man by whom they became pregnant. Knowledge of AIDS Transmission and Prevention Almost all respondents declared they have heard of HIV/AIDS but many of them had incomplete or superficial "knowledge". Only less than a half of those who have heard about HIV/AIDS knew that persons infected with HIV/AIDS can be asymptomatic. The majority of women who have heard about HIV/AIDS could identify three of the most frequent modalities of transmission: heterosexual relations, blood transfusions and use of contaminated needles. However, only 72% agreed that homosexual relations among men could transmit HIV/AIDS and more than a half thought that medical or dental visits carry a potential danger of transmission. About one-third believed sharing objects with an infected person, using public bathrooms or kissing on the mouth are also possible ways to get HIV/AIDS. About one in four women (27%) said that HIV/AIDS could be spread by mosquito bites and 9% indicated that shaking hands with an infected person could transmit the virus. Correct knowledge of transmission was positively correlated with education, especially in identifing male homosexuality as a risk factor for HIV/AIDS. No significant association was found between the self-assesed risk of infection and the respondents' experience with condoms. Only 29% of women who considered themselves at high risk of HIV/AIDS have ever used condoms, compared with 21% who did not agree they have any risk of infection and have ever used condoms. The majority of women who have ever used condoms said they wanted to prevent unintended pregnancies and none mentioned condom use as protection against HIV/AIDS or other sexual transmitted diseases . Conclusions The concept of modern methods of family planning was, and still is, poorly developed in Romania, and the change in legislation did not translate into a significant increase in contraceptive use; almost half of the couples are not using any method, and of those who do, most are using traditional methods and induced abortion when the method fails. Because of an overwhelming desire to limit family size, Romanian couples have decreased their fertility below replacement level, mostly through the use of abortion. Overall, the TFR decreased by 35% and the TIAR doubled. The extremely high rate of abortion appears to be the principal determinant of the decline in fertility since little changes have occurred in the prevalence of modern contraceptive use or contraceptive mix. The high prevalence of traditional methods, accompanied by high failure rates, results in more unintended pregnancies and consequently more abortions. The effect of switching from the use of illegal, unsafe abortions to legal abortions is reflected in the decline of the maternal mortality ratio (MMR). After many years of high rates of maternal mortality, more than 85% abortion-related, the MMR decreased between 1989 and 1992 from 170 to 60 per 100,000 live births, a decrease entirely due to the abrupt decline in the abortion-related deaths. Even with this decline, induced abortion is still associated with a relatively high risk of death, mainly because of the continuing use of unsafe abortions. Since the use of illegal abortion was a routine for many women in me past and since nonmedical abortion providers might be more accessible, more affordable, or more familiar, the practice of illegal abortion is likely to continue, especially among women who seek abortion beyond the legal gestational limit of 12 weeks. The low prevalence of more effective contraceptives contrasts with a high level of family planning awareness; almost all women who were currently in union declared that they had heard about at least one modern method, and 85% knew where to get the procedure or product. Unfortunately, family planning awareness is not enough to change contraceptive behaviors, especially when mistrust and preconceptions about modern methods, revealed in women's attitudes toward pill and IUD, are very common. Limited sex and contraceptive education, lack of adequately trained providers, shortage or uneven distribution of contraceptive supplies, and, in some instances, legal constraints are major reasons for the continued high rates of unintended pregnancy and induced abortion. Postabortion counseling is virtually unknown, and prenatal services, though highly attended (94%), do not address postpartum contraceptive needs. Although an increasing number of physicians and nurses are involved in family planning activities in addition to their other tasks, recent Ministry of Health regulations narrowed the eligibility of providers by requiring six months of continuous training in order to obtain "family planning competency." At the present time, only gynecologists may "officially" prescribe contraceptives and insert IUDs. Even when awareness for some methods is high (condom, pill, IUD), their use is hampered by mistrust and misconceptions. The prevailing public opinion, that modern contraceptives are harmful, is often supported by the medical community which often lacks experience in family planning. The availability of modern contraceptive methods continues to be an issue of great concern. Newly opened family planning clinics have very few, if any, contraceptive supplies, and their main source is international donors. Although since 1990 large quantities of contraceptive supplies (condoms, IUDs, pills, and barrier devices) have been imported by the Ministry of Health, these commodities are exclusively distributed through the central state pharmaceutical system, and family planning providers are often unaware of their existence. The absence of contraceptive logistics and managerial skills further contributes to shortages and uneven distribution of these supplies. Permanent methods of contraception are not promoted and legal provisions to support voluntary sterilization are absent. Previous legislation, which allowed tubal occlusion only for women with five or more children, for women older than 45 years of age, or for very limited medical reasons, has yet to be modified. The survey shows that of the 1.4% of women in union who reported tubal ligation as their method of contraception, only one in six had their procedures performed after December 1989. Less than 4% of fecund women in union who did not want any more children expressed interest in surgical contraception. Male sterilization is widely unknown, even among health professionals, and often is confused with castration. For family planning efforts to meet the needs of Romanian couples, better accessibility to modern contraceptives has to be ensured. A full range of quality contraceptive methods should be available to couples who want to space or limit their children. Active educational programs should be instituted for both the public and the health care providers. Information should also be made available on the health benefits of contraception. The education process should include men as well as women, and age-appropriate sex and contraceptive education should be initiated in schools. Policymakers and program managers should make an effort to decentralize the responsibility of providing services, and should encourage the training of general practitioners, nurses and social workers as service providers or counselors. Since the most common reason for using contraception and abortion is to have no more children, permanent methods of contraception should be promoted. CHAPTER I INTRODUCTION 1.1 Background Romania is an Eastern European country bordered to the north and east, by Republic of Moldavia and the Ukraine, former Soviet Union republics, to the south and east by the Black Sea and Bulgaria, and to the west by Hungary and former Yougoslavia. Romania covers an area of 148,000 square miles and the 1992 census reported a population of 22.8 million inhabitants. Over 89 percent are ethnic Romanians, seven percent Hungarians, nearly two percent Romi (gypsies) and the remainder (1.5 percent) include Germans, Ukrainians, Serbs, Turks and other nationalities. More than a half of the population (54.4 percent) live in urban areas, and two million reside in the capital city of Bucharest. The rural population is settled in villages and communes (big villages that serve as the administrative center for 3 to 5 villages). The country is administratively divided into 41 districts called judets (see map - Attachment B). National programs are developed and coordinated at the national level and are administered, along with other local government activities, at the judet level. Romania is divided into three major geographic regions: Moldavia, Vallachia (Muntenia), and Transylvania. Economic, social, ethnic and cultural differences still persist among the regions due to Romania's unique history and geographical location halfway between the East and the West, sharing much of its tradition with both and yet not completely a part of either. 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. The Ministry is assisted by several state-supported academic institutes, such as the Institute of Hygiene and Public Health, the Institute for Health Services and Management, and the Institute for Mother and Child Health Care (IMCC) which serve in an advisory capacity and carry out health research. The Ministry is organized into a number of administrative units, including the Directorate for Mother, Child and Adolescent Health where a recently established unit is responsible for family planning and sex education activities. Local health care is administered by the local authorities and the Ministry of Health through the judet health offices which are called "District Sanitary Directorates". These directorates manage all health services in their district: the district hospital, other local hospitals, all polyclinics (outpatient clinics used for specialist consultations and referrals) and all rural and urban dispensaries staffed by general practitioners. There are 243 hospitals , 540 polyclinics (most of them in urban areas), and 5,883 dispensaries (almost equally distributed in urban and rural areas). Throughout the country, 21 referral hospitals are involved in teaching activities (Ministry of Health, 1992). About 48,500 physicians work for the Ministry of Health (one physician per 475 1 population) of which approximately 1,500 OB/GYN specialists. There are presently 135,000 nurses, but it is estimated that 25,000 more are needed. For 10 years, beginning in 1980, the basic nursing curriculum was integrated into the four years of high school education followed by another year post-secondary school. Formal midwifery training stopped in 1978; therefore most midwifes were trained as hospital nurses and had on-the-job training. Starting with 1990, several postgraduate nursing schools were reopened and specialist training for physicians started again. Nonetheless, curricula need to be updated and family planning training, banned before December 1989, needs to be added. Former President Ceausescu's legacy left a terrible burden for Romanians in respect to many aspects of life, but one of the most dramatic has been reproductive health (Shroff, 1992). As a result of his pronatalist policy introduced in 1966, abortion, contraception and sex education were prohibited, and draconian measures were introduced to enforce compliance with the law. After a brief increase to 22 per 1000 in 1970, the crude birth rate began to fall and continued to fall, to a rate of 14 per 1000 in 1990, despite reinforcement of the pronatalist law in 1985. However, the maternal mortality rate, similar to other industrialized countries before the 1966 law went into effect, skyrocketed until it reached a level 10-times higher than any other European country. For the decade 1980-1989, the average maternal mortality rate was 150/100,000 live births and 80 to 85 percent of maternal deaths were reported to be due to illegal abortion. It is estimated that a total of almost ten thousand women died during the period 1966-1989 and many others had been left with complications leading to infertility or sterility as a consequence of self induced or "backstreet" abortion procedures. After the December 1989 uprising, one of the first acts of the then provisional government was to legalize abortion "on request" and family planning. Approximately one million legal abortions were performed in 1990 as a direct result of the repeal of the restrictive law and the unavailability of contraceptives. Subsequently, the maternal mortality rate declined dramatically (by 60% in one year) as most of the induced abortions were performed by skilled physicians in hospitals or clinics. In 1992 the maternal mortality rate declined even further, from 85/100,000 (1989) to 60/100,000 live births, almost entirely as a result of the decrease in the abortion-related mortality rate (source: the MOH/MCH reporting system). However, the maternal mortality rate in Romania remains one of the highest in the Europe. According to non population based studies, there is a low prevalence of modern contraceptive use and strong reliance on traditional family planning methods whose high failure rates lead to high levels of unintended pregnancy. As part of health care reform, the current government plans to introduce and generalize family planning services throughout the country. A major loan was received from the World Bank in order to strengthen the health system infrastructure and to improve health services, including drug availability and institutional development. Family planning services are an important part of the World Bank project which designated funds for opening 11 referral centers staffed mainly by gynecologists and 230 "contraceptive cabinets" set up in hospitals, polyclinics and dispensaries. A certain emphasis was placed on developing the Family Planning and Sex Education Unit (FPSEU) within the Ministry of Health whose tasks include: developing a family planning 2 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 in 1991, 1992 and 1993 along with the increase in contraceptive availability were considered early results of the recently developed FP policy. However, the lack of a communication and reporting system within the newly developed FP network combined with no 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 Romanian Ministry of Health decided that the best and the 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 Romanian Reproductive Health Survey (RRHS) was conducted during July-December 1993, among 5,283 women of childbearing age interviewed in their homes. The response rate was 92% (4,861 completed interviews). Since this was the first national household reproductive health survey in Romania, the high response rate not only adds confidence in the data but also makes this methodology a valuable precedent for gathering population based health information. The Preliminary Report, published in January 1994, described only some of the key findings of the survey. This Final Report addresses the following topics: general characteristics and marital status of women with completed interviews; fertility levels, trends, preferences and planning status of pregnancies; induced abortion levels, trends and differentials; contraceptive use; awareness, use and attitudes about modern and traditional methods of contraception, reasons for not using contraception and future intention of use; prenatal care; sexual experience of young adult females and contraceptive use at first intercourse; cervical cancer screening and smoking history; and knowledge about prevention and transmission of HIV/AIDS infection. Tabulations and analysis of data were performed by geographic areas and selected socio- demographic characteristics. 1.2 Objectives of the Survey The improvement of reproductive health in Romania is a difficult and complex task which cannot be achieved only through legalization of abortion and contraception. The survey was specifically designed to meet the following objectives: -to assess the current situation in Romania concerning abortion, contraception and various other reproductive health issues; -to enable policy makers, program managers and researchers to evaluate and improve existing programs and to develop new strategies; 3 -to measure changes in fertility and contraceptive prevalence rates and study factors which affect these changes, such as geographic and socio-demographic factors, breastfeeding patterns, use of induced abortion, and availability of family planning; -to identify and focus further reproductive health studies toward high risk groups. 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 RRHS was provided principally by the United States Agency for International Development (USAID) through the Center for Development and Population Activities (CEDPA), and the United Nations Population Fund (UNFPA). Additional funding was provided by UNICEF and the Romanian Academy of Medical Sciences. Fieldwork was conducted by the Institute of Mother and Child Care, Ministry of Health (MOH), which coordinated the recruitment and training of interviews and all aspects of data collection. The National Commission for Statistics provided the sampling frame based on the recently completed 1992 census. The Center for Health Statistics in the Ministry of Health (CHS/MOH) reviewed the questionnaire and provided personnel to carry out data entry and edit operations. The Association for Public Health and Management was responsible for financial accounting. 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 all technical areas of the survey. Interviews were administered at the homes of respondents by 20 intensively trained female interviewers, most from the Institute of Mother and Child Care (IMCC) and the CHS/MOH. There were five survey teams, each headed by a fieldwork supervisor and one field work coordinator. Training was carried out immediately before the survey field work began and lasted six days. Interviewer training was organized and conducted by staff from the IMCC and DRH/CDC. In parallel with the first two weeks of field work, a DRH/CDC computer specialist installed data entry/edit software and trained the Romanian 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 Czech Republic RHS. This core questionnaire was modified, including adding modules targeted to explore important issues for Romania, such as induced abortion and maternal mortality. The survey instrument was then reviewed by Romanian experts in reproductive health and family planning, as well as by AID and AID cooperating agencies who have worked in Eastern Europe. Based on these reviews, a pretest questionnaire was developed and field tested in April 1993. 5 The RRHS questionnaire covered a wide range of topics related to reproductive health in Romania. The specific areas included were: - Social, economic and demographic characteristics - Pregnancy history - Knowledge and use of contraceptive methods - Sexuality and contraception among young adults - Use of maternal and child health services - Morbidity during pregnancy - Women's health issues - Knowledge and attitudes about contraception - Knowledge about HIV/AIDS The questionnaire had two components: (1) A short household module that was used to collect residential and geographic information, as well as selected characteristics about all women of childbearing age living in sampled households, and information on interview status. This module was also used to select a respondent randomly when there was more than one eligible woman in the household. (2) The longer individual questionnaire collected information on reproductive health topics discussed below. For Hungarian language speakers, the interview was conducted in their native language. The major subjects on which information was collected are: pregnancies and childbearing (a history of all pregnancies and births, including use of abortion and planning status of pregnancies); family planning (knowledge and history of use of methods of preventing pregnancy, reasons for use of less effective methods of contraception, pregnancy intentions, and fecundity); maternal and child health (health information about the most recent pregnancy and birth and the use of services); young adult reproductive health (information on sexual relations and pregnancy among females 15-24 years old); women's health (health behavior and use of women's health services); reproductive health knowledge and attitudes (especially regarding birth control pills and IUDs); knowledge about HIV/AIDS transmission and prevention; and socioeconomic characteristics of women and their husbands/families. The sisterhood module to estimate maternal mortality was also part of the questionnaire. Most issues have been examined by to geographic, demographic, and socio-economic characteristics, making it possible to identify the segments of the population with specific health needs or problems. 6 2.3 Sampling Design The 1993 RRHS was designed to collect information from a representative sample of women of reproductive age throughout Romania. 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 Romania when the survey was carried out. The survey employed a stratified sample with independent estimates for Bucharest, the capital city, and the 40 judets outside of Bucharest, or the Interior. Bucharest, together with its surroundings, the Agricultural Sector of Ilfov, is the equivalent of a judet. The 1992 census was used as the sampling frame (Comisia Nationala pentru Statistica, 1992). Since there were roughly equal numbers of urban and rural households in the Interior, the Interior sample was designed to be self-weighting. With a projected area probability sample of 5,000 women, 1,000 in Bucharest and 4,000 in the Interior, regional estimates are also possible for the Interior. Based on census data (percentage of households with at least one women 15-44 and unoccupied households) and a projected response rate of 90%, a total of 12,387 households were sampled to obtain complete interviews for approximately 5,000 women. Bucharest was oversampled and represents 22 percent of the sample, although it includes 11 percent of the total population. The first stage of the three-stage sample design was a selection of "Census Sectors" with probability proportional to the number of households recorded in the 1992 Census. This was accomplished using a systematic sample with a random start in both strata or domains. In the second stage of sampling, clusters of households were randomly selected in each Census Sector chosen in the first stage. Cluster size determination was based on the number of households required to obtain 15 interviews per cluster, on average, in Bucharest, and 20 in the Interior. To obtain an average of 15/20 interviews, cluster sizes varied from 39 to 50 households due to different proportions of unoccupied household and variations in the proportion of households containing females 15-44 years of age by geographic area. Finally, one woman between the ages of 15 and 44 was selected at random for interviewing in each of the households. 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. Survey results are also weighted to adjust for the oversampling of households in Bucharest. 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. As mentioned above, interviews were conducted at the respondent's homes by trained female interviewers. These interviews generally lasted 30 to 50 minutes. Almost all women selected to participate in the survey agreed to be interviewed and were very cooperative. Of the 12,583 households selected, 5,283 were found to include at least one 15-44 year-old woman. Of this number 4,861 were successfully interviewed, for a response rate of 92.0% (Table 2.1). Only 1.1% of selected women refused to be interviewed, while another 6.2% could not be located. Response rates were slightly better in Bucharest and other urban areas than rural areas. 7 The age distribution of the RRHS sample closely reflected that of the female population as a whole (Comisia Nationala pentru Statistica, 1993A). As shown in Table 2.2, the sample population is essentially within two percentage points of the census population in each age group. In urban areas there is a slight overrepresentation of women 15-19 years old and slight underrepresentation of women 20-24 years of age. This is probably due to the greater difficulty in finding 20-24 year old women at home, since they are more likely to work or be attending University level classes. 8 9 The sample population by marital status is compared with the census in Table 2.3. After age 24, the sample includes from three to six percent more married women and two to five percent fewer never married women. This is probably explained by the fact that women in consensual unions were considered married in the survey, but defined as not married in the census. Four percent of women in the survey reported themselves to be in a stable consensual union. By age 30, more than 95 % of women in Romania have entered a martial union. Table 2.4 shows the similarity of number of children born alive between the census and the RRHS, another indication of the representativeness of the RRHS sample. 10 CHAPTER III CHARACTERISTICS OF THE SAMPLE 3.1 Characteristics of the households Table 3.1 displays information on the size of the households where at least one eligible woman 15- 44 was identified, by residence and region. Overall, 85% of the households are constituted by one family and this percentage is even higher in urban areas (90%). In rural areas one fourth of the households contain either two (23%) or more families (2%). Excepting Bucharest which has mostly single family households (90%), a negligible difference in the number of families per household is observed among regions (82-86%). 11 More than half of the households have three or four persons and this proportion increase to almost two-thirds in urban areas. Households in Bucharest contain considerably fewer persons compared with the other regions. For instance, 13% of households have only two persons (presumably childless couples) compared with about 7% in other regions. Only 18% of households have five or more persons, whereas in Transylvania these households represent over 30%, in Vallachia over 37% and in Moldavia 42% of the households. On average, a household is composed of 4.1 persons. As expected, there is a substantial difference in the average size between the urban and rural areas. The average household size of almost 5 persons in rural areas can be partially explained by higher fertility levels (see Chapter VI). The mean household size is lowest in Bucharest (3.7 persons) where a much higher proportion of single women aged 15-44 live and fertility rates are low. The level of household crowding is another important household characteristic. Two measures of household crowding were used. One was the estimated number of persons per room. On average, there were 1.6 persons per room and no significant difference was noted between urban and rural areas. The other measurement was the number of rooms occupied by a family. Overall, 80% of families live in at most three rooms (8% in one room, 36% in two rooms and 35% in three rooms) and this proportion increases to almost 90% in urban areas (data not shown). The average number of rooms per family is 2.8 rooms. Only in rural areas is the mean number of rooms somewhat higher (3.5 rooms). Along with a number of household amenities (bathroom, flush toilet, central heating, television, video, telephone, automobile and second residence) this household characteristic was used as one variable in constructing a socio-economic index (see below). Table 3.1.2 and Figure 3.1 displays the percent distribution of households with selected amenities by residence. Among basic services, bathroom and flush toilet are available in almost two-thirds of the households. About half of household have central heating and only 38% have a telephone. Among durable consumer goods, television is available in almost all households, whereas automobiles and VCR's in only 32 and 19%, respectively. Very few families own a vacation home or other type of second residence. The proportion of household with such amenities varies greatly between urban and rural areas and, excepting TV's and second residence, is much higher in Bucharest compared with the other regions. The greatest disparity is observed for central heating and flush toilets; households in urban areas are much more likely to have these basic services compared with rural areas -13 times and six times, respectively. The socio-economic index was calculated by creating for each respondent a score of the amenities available in the household plus the availability of at least 4 rooms. Equal values were assigned for possesion of each of these amenities. According to this calculations, 3.5% of the households do not have a single amenity (score=0), 15% have only one, 13% have two, 7% have three, 19% have four, 18% have five, 14% have six and 11% have seven or more. The score was further divided into terciles to create three levels for me socio-economic index: low, for respondents with 0-2 amenities, medium (3-5 amenities) and high (6-9 amenities). 12 13 3.2 Characteristics of the Eligible Women General characteristics of women with completed interviews, by residence and region, are shown in Table 3.2.1. Overall, 39% of the sample are young adults from 15 to 24 years of age. The age distribution is younger in rural areas where the young adults represent 46% of the eligible women. The same proportions were found in the 1992 census, as shown in the previous chapter. Only 6% of women did not complete primary school. Over 40% have completed secondary school or gone to post-secondary education. Women in urban areas are more likely to have higher education than women in rural areas. The urban-rural difference is most pronunced at the postsecondary level; residents of urban areas are three times more likely to attain this level of education. By region, the highest proportion of better educated women reside in Bucharest (23 %), whereas for Vallahia, Transylvania and Moldavia this proportion is only about 10%. As expected, fertility has been higher in rural areas. This is reflected in the 22% of rural women who have had three or more children compared with 12% in urban areas. The largest family size is observed in Moldavia (21 %) and the lowest in Bucharest (9%). Two-thirds of women with completed interviews are currently married (63%) or live in a stable consensual union (4%). There are no important differences geographically in marital status. Most respondents are orthodox (88%), protestants (6%) or catholics (4%), with no significant differences between the urban and rural areas or among regions; the only notable exception is Transylvania where fewer respondents are orthodox (75%) and a much higher proportion are Protestants (15%) and catholics (9%). Less than one percent declared that they have no religion. Ninety percent of respondents are ethnic Romanians, 6% Hungarians, 3% gypsies and 1% other ethnic groups. In Bucharest 97% of respondents are Romanian whereas Hungarians are more likely to reside in Transylvania (18%) and gypsies in Moldavia and Transylvania (5%). According to socio-economic status, urban women are much more likely to be classified as medium or high socio-economic level (two times and seven times, respectively) than rural women. The highest proportion of respondents with socioeconomic status above average (50%) are living in Bucharest, whereas the lowest proportion is in Moldavia (only 15%). In urban areas, over half (59%), and as many as two-thirds of women in Bucharest, are employed outside the household. In rural areas, only 30 percent work outside the household. Marital status is shown for each residential area by age group in Table 3.2.2. By age 24, over 60% of women are married, in a stable consensual union or have been previously married. By age 34, this proportion rises to 99%. Women marry younger in rural areas; 17% of rural women aged 15-19 already have marital experience compared with only 10% in Bucharest and other urban areas. Marriage dissolution among older women is higher in Bucharest. A more detailed analysis of age at marriage is included in Chapter VI. 14 15 Table 3.2.3 presents the percent distribution of the respondents by the highest level of education attained, according to age and residence. Overall, younger women have completed higher levels of education than older women. For instance, about 60% of the respondents aged 20-24 have completed at least secondary school, compared with only 40% among respondents aged 35 or older. As expected, women in urban areas are better educated in each age group; among women aged 20- 24 residing in Bucharest or other urban areas, 73% and 67%, respectively, have at least completed high school, compared with only 50% in rural areas. The urban-rural disparity in education is 16 much higher among older residents. Women over 35 are almost three times and two times, respectively, more likely to have completed at least secondary school if they are residents of Bucharest or other urban areas. 17 18 CHAPTER IV FERTILITY One of the objectives of the RRHS was to assess the current level of reproductive behaviors, and their trends, and to identify factors which might influence their changes. In spite of being deeply private and personal matters, reproductive behaviors are important to investigate because they profoundly influence the size, structure and direction of the society and, at the same time, have important health planing implications in terms of health services needs they generate (such as family planning and maternal and child health services). The findings presented in this chapter are particularly useful in assisting policy makers and program managers to design programs which affect the reproductive behavior of the population and to tailor them for meeting the needs of key subgroups. In order to obtain information on reproductive patterns, the questionnaire included a series of questions about marriage, sexual activity, childbearing, desired family size, a complete pregnancy history, regardless of the outcome (including use of abortion), planning status of pregnancies, a separate abortion history for the last four abortions that have occurred since January 1988, and a monthly calendar of pregnancies and contraceptive use since January 1988. In addition, detailed information regarding contraceptive knowledge, attitudes and practices were collected (see Chapter V). 4.1 Fertility Levels and Trends Romania is a low fertility country in spite of almost 25 years of restrictive abortion and contraception legislation and a firm pronatalist policy. Legal provisions mandated in 1966 narrowed the use of induced abortion and modern contraception for very limited medical and social reasons. However, even though extreme measures were taken to enforce compliance with this law, the fertility levels in the long term were far below expectations of the government. Although fertility in the first years after the restrictive legislation was enacted reached 3.6 births per woman -more than double the 1.7 births per woman registered in 1965-1966- the total fertility rate (TFR) fell to 2.9 in 1970 and a steady decrease continued until it stabilized around 2.3 in the eighties (Figure 4.1.1). After the December 1989 revolution, one of the first decisions of the interim government was to make abortion available on request through 12 weeks of pregnancy and to eliminate abortion committees and waiting time before the procedure. Clinics have been inundated by women seeking abortions and fertility has sharply declined. As will be seen later in this chapter, the descending fertility curve closely reflects the desire of Romanian couples for a small family size and for limiting childbearing . 19 In order to estimate current fertility and changes after the restrictive abortion legislation was reversed, we calculate age specific fertility, induced abortion and pregnancy rates for two 36 month periods, June 1987-May 1990 and June 1990-May 1993. The total pregnancy rate (TPR), total fertility rate (TFR) and total induced abortion rate (TIAR) for these two periods are computed by accumulating the age specific fertility rates for each event. The TPR, TIAR and TFR can be defined as the average number of events of each type (pregnancies, births, and induced abortions) that 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 which occurred during the two 36 month periods preceding the survey and grouping them (in 5 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 5-year age group by those mothers during the two 36 month periods preceding the survey. After 1990, the total fertility rate dropped abruptly, declining by almost one third (from 2.3 to 1.6) whereas the total abortion rate has doubled (Figure 4.1.2). Although national vital statistics show that the fertility started to decline prior to the end of 1989, this process has been more dramatic in the recent years. It is important to note that the TFR calculated from the survey data for the most recent 3-year period (1.56), is comparable with the average TFR for 1990-1992 from the most recent vital statistics estimate (TFR=1.63), available from the National Commission of Statistics (Ministerul Sanatatii, 1993). 20 21 All age specific fertility rates have sharply declined, except for women aged 40-44, whose rate is very low in both periods, and teenagers, who experienced a 19 % decline (Table 4.1.1). Almost 70 percent of the TFR is contributed by women aged 20-29 in both periods of time, in spite of the considerable decrease in fertility rates for these women. Fertility trends for women under 30 years of age are particularly important in Romania, where by the age of 29, 92% of women have already given birth to their first child (Table 4.1.2). Although the greatest decrease in fertility was experienced by women 30-34 and 35-39 years of age, their already low age specific fertility rates account for only 11% and 4%, respectively, of the overall fertility. Table 4.1.1 also presents age specific marital fertility rates. As expected, marital fertility rates for all age groups are higher than age specific fertility rates for all women. These findings are consistent with the cumulative past fertility of women interviewed in the RRHS calculated as the percent distribution of women by number of live births classified by current age of the woman at the time of the interview (Table 4.1.2). Overall, 35.7% of all women aged 15- 44 had not yet had a live birth at the time of the interview, but only 11.1% of women currently in union had not had their first child. 22 23 4.2 Fertility Differentials Table 4.2 shows differences in fertility rates by residence, education and socioeconomic status. There is a substantial difference in fertility between urban and rural residents. Urban women have, on average, almost one child less then rural women in both time periods examined. However, the differences in age specific fertility rates indicate a more abrupt decline of fertility among the younger urban residents (women aged 15-24), while for the other age groups the decline was parallel in urban and rural areas. There is an inverse relationship between fertility and education, with the least educated women consistently reporting the highest fertility rates. Nevertheless, fertility differences according to education level have diminished in the last three years. While the TFR for women who never attended high school dropped dramatically (from 3.47 to 2.26), women who attended high school also experienced large declines in fertility, but the most educated women had minimal change in fertility. 24 Overall, the difference in fertility between less educated women and the best educated women fell from 2.4 children to only 1.2 children. For the less educated women a substantial decrease can be seen in all age groups. Socioeconomic status is also inversely related to fertility level. The highest rates are experienced by women classified as low socioeconomic status in both periods of time in spite of a 34% reduction in the TFR. The greatest decrease in fertility was experienced by women in the middle socioeconomic status category who are reporting almost the same TFR as the high socioeconomic status women, in the last three years. 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. At the time when the survey was carried out, two thirds of women aged 15-44 were currently married or living with a partner, 5.3% were previously living with a husband or partner but are currently separated, divorced or widowed, and 27.5% have never been married (Table 4.3). The proportion of all women who were in union starts at about 11% among adolescents, increases rapidly to 58% among women aged 20-24, reaches a maximum of 93% for women aged 30-34 and then slightly declines for older women, as a result of marital dissolution since the proportion of ever married women for these age groups is the highest. This proportion does not significantly vary by region, with the exception of Moldova, where the percentage of women in both formal and consensual union is only 64% and 30% have never been married. Consensual unions are higher among women with primary education. The proportion of never married women decreases abruptly from almost 88% among teenagers, to 38% among women 20-24 years of age and to 8% among women aged 25-29. It also varies with the education level, being higher among better educated women, most probably because these women tend to be younger and tend to delay marriage after completing their education. Separation, divorce and widowhood increase with age, reaching a peak of almost 9 percent among women aged 40-44, and are more common among women residing in Bucharest, who have a high level of education and who are working outside the house. 25 26 4.4 Age at First Intercourse, Union and Birth Table 4.4.1 presents information on age at first sexual relation, first union and first birth for all women, by current age for different age group cohorts. The overall and the cohort median age for each event is also displayed. The median age represents the age by which 50% of women in a cohort (age group) have experienced the event. Age at first intercourse and age at first union are usually regarded as proxy measures for the beginning of a woman's exposure to the risk of pregnancy. If these events are delayed, the number of years a woman will be exposed to the risk of pregnancy is diminished. Age at first birth is also an important fertility indicator since postponing the first birth might contribute to the decline of total fertility rate. In Romania sexual abstinence before marriage was, and still is, a common practice, mostly dictated by a strong tradition which values chastity before marriage and condemns pregnancies out of wedlock (See Chapter IX). Therefore, the proportion of women who ever had a sexual relation is only 3 percentage points higher than the proportion of women ever in union and the median age at first intercourse for all women is 20.2 years, only 2.4 months lower than the median age at first union (20.4 years). If we compare different cohorts at different ages of initiation of sexual activity and union, we could determine wheather or not the age of onset of these events has been changing over time. Both age at first intercourse and at first union are similar for different cohorts, excepting the cohort of women aged 20-24 years. For example, among women currently aged 20-24, 44% became sexually active and 38% began their first union before their 20th birthday whereas among women currently aged 35 or older, about 49% and 47%, respectively, did so. Table 4.4.1 also shows that all but one age cohort have about the same median age at first intercourse and at first union. The only cohort with a longer interval between the onset of sexual activity and the first union is represented by women aged 20-24 years for whom the median age at first intercourse is 6 months lower than the age at first union. Overall, half of these women initiated sexual activity by age 20.5 years and began their first union by age 21.0. This finding might signal a transition in sexual behaviors toward delaying the first union resulting in a greater difference than seen in the other age groups. Also, age at first birth did not change much until recently. More than a fourth of Romanian women currently aged 25 or older had their first birth before reaching the age 20 and only about a fourth had it postponed after age 25. About 90% of them had their first child before reaching the 30th anniversary (not shown). The median age at the first birth for these age groups is very similar (ranging from 21.7 to 22.2) and is two years higher than the median age of first sexual relation. However, women aged 20-24 are clearly less likely to follow this pattern since only 20% had their first live birth before the age 20 and their median age for this event is 23.4, more than three years later than the median age at first intercourse. 27 28 Differentials in the median age at first intercourse, first union and first birth by selected characteristics are shown in Table 4.4.2. Urban women initiate sexual activity, union and childbearing at a slightly older age than rural women. The median age at first intercourse, first union and first birth are delayed one year for women residing in urban settings than for women living in rural areas. The median age at first birth for women residing in Bucharest is postponed even further (two years). Also, the intervals between these events are longer for urban women than for rural residents, contributing to the decrease in fertility rates for urban women. Differentials in median age of experiencing these events are even greater for different levels of education. If the highly educated women are compared with those with primary education a significant delay in the onset of these events can be observed (4 years for onset of sexual relations, 5 years for starting the first union and 6 years for the onset of childbearing). There are also smaller differentials between different socioeconomic levels, women with a higher level having later onset of these events. 29 30 4.5 Recent Sexual Activity In Table 4.5.1 information on sexual activity status is presented by marital status. More than three percent of all women were either pregnant or in postpartum abstinence at the time of the interview and were not included in the analysis of recent sexual activity. Overall, 76 percent of women reported sexual experience but this proportion drops to 13 percent among never married women. Not all women who have had intercourse are currently sexually active (in the last month). Only 60 percent of all women 15-44 had sexual relations within the last month; that means, 79 percent of sexually experienced women were currently sexually active. Current sexual activity is highly influenced by marital status; among currently married women, 85 percent reported at least one sexual relation within the last month whereas only 23 percent of previously married women and 7 percent of never married said so. Therefore, women who are currently in union constitute 96% of those clasified as currently sexually active. Most of the 31 currently in union constitute 96% of those classified as currently sexually active. Most of the formerly married women (72%) had their last intercourse 3 or more months ago but most of sexual experienced never married women (63%) had their last intercourse within the last two months. Table 4.5.2 shows that, among currently in union women, the proportion of currently sexual active may vary by background characteristics but this differences are not significant. The single notable exception is for the youngest subgroups (15-24) and for nulliparous women most likely because a larger proportion of them are pregnant or in postpartum abstinence. Among women currently in union who reported sexual activity in the last 4 weeks, the average number of sexual relations was 7. The coital frequency diminishes with age and number of living children. Both these variables are correlated with duration of marriage which is an important determinant of coital frequency. 32 33 4.6 Planning Status of the Last Pregnancy For each pregnancy outcome after 1987, women were asked a series of questions to determine whether the pregnancy was planned (desired at the time it occurred), mistimed (wanted at a later time) or unwanted. Mistimed and unwanted pregnancies together are classified as unintended pregnancies (Westoff, 1976). The respondents were asked to recall accurately their thoughts at the moment they found out about their pregnancy. Although some reluctance in reporting induced abortion was observed and postpartum rationalization might occur, many women were clearly willing to report unwanted conceptions. Table 4.6 shows the percent distribution of the reported planning status for the last pregnancy, in the last five years, for women in union by selected characteristics. Only 36% of women said their most recent pregnancy was planned, whereas 10% report it as mistimed and 51 % unwanted. Thus, almost two thirds of women reported unintended pregnancies at the time of conception. There is a significant difference in the planning status of last pregnancy between urban and rural residents. Almost 70% of women living in Bucharest or other urban areas reported unintended pregnancies compared with 55% of women in rural areas (p<0.01). The planning status of the most recent pregnancy is strongly correlated with pregnancy outcome. Almost 80% of women whose last pregnancy resulted in a live birth say the conception was planned, 6% mistimed, and 11% 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 of women whose last pregnancy ended in miscarriage or stillbirth had reported it as an unwanted conception (30%), almost three times the proportion of women who are currently pregnant or women with live births who reported an unwanted pregnancy. One can only speculate that some of these outcomes may have been induced abortions reported as spontaneous abortions or stillbirths. The proportion of women with unwanted pregnancies increased with increasing numbers of living children and with age. The proportion rises abruptly from 4% of childless women to 28% of women with one child, who said they did not want their last pregnancy, to more than 70% of the women with three or more children. The same pattern can be seen when the planning status of the last pregnancy is correlated with age--from 8% of women aged 15-19 years who reported that the last pregnancy was unwanted to more than 78% of women aged 35 or more. Childless women and women with one child are much more likely to have mistimed pregnancies. Among younger women, spacing failures are also more common. From 14 to 20 percent of younger women report spacing failure; this proportion drops abruptly —to 4% or less--among women aged 30 years or more, probably because few of these women want any more children. Education level does not show a strong relationship with planning status for the last pregnancy. However, almost two-thirds of women with primary education report that their last pregnancy was unwanted. Better educated women report higher levels of mistimed pregnancies. The proportion 34 of women, who declared their last pregnancy to be mistimed, increases from 3% for less educated women to 15% for women with higher education. Since better educated women tend to be younger, they are more likely to have not completed their desired childbearing and are at greater risk of having a higher level of mistimed pregnancies. The final analysis of the determinants of unintended pregnancies will have to be accomplished by multivariate analysis. 35 4.7 Changes in Planning Status of Pregnancies In order to study changes in the planning status of pregnancies associated with changes in legislation, we asked the same question with three options for all pregnancies that occurred in the last five and one half years, regardless of the outcome or the woman's marital status. Table 4.7 shows a comparison of the planning status of pregnancies ended after the change in legislation with that of pregnancies ended between January 1988-May 1990. Several changes in planning status are notable. Overall, both mistimed and unwanted pregnancies increased by about one- third, yielding a proportion of 67% unintended pregnancies after the legislation was changed, compared with 51% before the repeal of the abortion law (p < 0.01); planned pregnancies dropped from 49% to 33%. 36 The residence differentials are important in both periods. Bucharest residents consistently reported the highest proportion of unintended pregnancies (63% and 75%), but more striking is the rapid increase in unintended pregnancies among other urban women (from 48% to 71%) and among rural women (from 43% to 59%). According to pregnancy outcome, the proportion of live births reported as unwanted pregnancies fell from 12% to 8% after the repeal of the restrictive law. The planning status of pregnancies ending in induced abortion doesn't change; almost all of these pregnancies (96%) were unintended. It should also be noted that a relatively high proportion of women whose pregnancy ended in miscarriage or stillbirths in both periods had reported it as an unwanted conception (21 %); this percentage is almost three times that of women with live births who reported an unwanted pregnancy after the change in legislation. One can only speculate that some of these outcomes may have been induced abortions reported as spontaneous abortions or stillbirths. Pregnancies declared as unwanted by the youngest women (15 to 19) have more than doubled in the last 3 years, those unwanted by women aged 20 to 34 have increased by more than 40%, whereas unwanted pregnancies reported by older women (aged 35 to 44 years) increased only by 12%. The least educated women consistently reported the highest level of unwanted pregnancies (49% and 68%) whereas women with higher education are more likely to report higher proportion of mistimed pregnancies. 37 4.8 Unplanned and Unwanted Pregnancy Rates Table 4.8 presents the intended and unintended components of the total pregnancy rate (TPR), total fertility rate (TFR), total induced abortion rate (TIAR) and total rate of other pregnancy outcomes during the same two periods of time using the information on planning status for pregnancies ending after 1987 and before June 1993. In addition, the ratios of unintended rates to the total rates for each pregnancy outcome was calculated. Overall, the unintended pregnancy rate had increased from 2.2 to 3.5 pregnancies per woman leading to a striking level of unintendeness for two thirds of pregnancies occurring in the last three years compared with the already high level of 52% before the change in legislation. The increase is due to a surge in the unwanted pregnancy rate (data not shown) from 1.6 to 2.9 pregnancies per woman, whereas there is no difference in the mistimed component of unintended pregnancy rate. In the last three years, the unintended pregnancies, especially those unwanted, almost always end in induced abortion and unintended births are infrequent events; only 13% of live births were reported as unintended, either mistimed or unwanted. These findings contrast with the previous period when almost a quarter of live births were unintended. Since me mistimed component of the birth rate remained basically unchanged, 7% and 8%, respectively, most of these unintended births that occurred in the past were unwanted; thus, the new legislation had an important impact in averting unwanted births. Unfortunately, this is achieved by heavy reliance on abortion instead of an increase in the use of effective contraception. A common indicator of fertility preferences is represented by the wanted fertility rate (Bongaarts, 1990). The wanted fertility rate was calculated for the last three years preceding the survey in the same manner as regular fertility rate, except that only wanted pregnancies, either planned or mistimed, ending in live births were included in the numerator. This estimate is used for approximating the extent to which fertility would be reduced if women were completely successful in averting unwanted births. Wanted fertility rate is defined as the level of fertility that theoretically would result if all unwanted births were prevented. The total wanted fertility rate (TWFR) represents the number of wanted births a woman would have by the age of 44 given present age-specific wanted fertility rates. Therefore, if the TWFR is compared with the actual TFR, the potential demographic impact of averting unwanted births can be estimated. Figure 4.8 presents a comparison of total wanted fertility rates arid total fertility rates by residence and by education after the abortion legislation was changed. The comparison underlines that women will bear very few unwanted births if they continue to give birth at the level of the last three years. According to the survey data, if unwanted births did not occur, the total fertility rate in Romania would be 1.4 per woman instead of 1.6, the actual figure for the three-year period before the survey. Thus, through the use of abortion, Romanian women have largely succeed in attaining their fertility aspirations and this practice is likely to continue unless modern contraceptive use 38 39 will substitute abortion in regulating fertility. The figure also shows that, regardless of the place of residence or level of education, the gap between the TWFR and TFR is very narrow. The largest gap is notable for rural women and women with the lowest educational level, indicating that these women are less successful in achieving their fertility goals. 4.9 Desire for Additional Children The respondents in me RRHS were asked about future fertility preferences and ability to get pregnant. Table 4.9.1 shows the distribution of women currently in union by desire for additional children according to the number of living children and by age group. Only 10% of these women desired a child in me near future (within two years). The figures in the last column indicate that almost 60% of women in union do not want to have any more children, and 5 % want to wait at least two years before having another child; 40 almost 20% think they cannot become pregnant, citing either diagnosed infecundity or gynecological surgery other than contraceptive sterilization (infecund), or that they have tried to become pregnant for at least two years without success (subfecund). The desire for additional children decreases rapidly with increasing number of living children. About 75% of women with two or more children do not want any more children whereas less than 5% would like to have another child. Interestingly, among women with no children only 61 % are fecund and want to have a child in the future, two-thirds of them within the next 2 years; 6% don't want any children and 32% are subfecund or infecund. Most women reporting infertility or subfecundity are over 35 years of age. According to age the of respondents, which is correlated with the number of living children, older women are much more likely to want no more children than younger woman. Younger woman are also much more likely to space the next pregnancy than older woman. Of women aged 15 to 24, 22% want to delay having a child by two or more years whereas none of me respondents aged 35 or more say they want to space the next pregnancy by 2 or more years. 41 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. Table 4.9.2 and Figure 4.9.2 are restricted to fecund women and shows the percentage of women currently in union who want no more children by number of living children and by selected characteristics. When we exclude from the denominator women who are subfecund or infecund, these women represent almost three-quarters of all women currently in union. One half of women with one child and almost all women with two or more children do not desire any more children. Urban women are more likely to want no more children than rural woman until they have three children when the figures converge. Childless residents of Bucharest are more likely to want no children (20%) than other urban or rural residents. The desire for additional children decreases with age for women with fewer than three living children and is almost universal for women with three or more living children. Overall, less educated women are more likely to want no more children (83%), probably due, in part, to the higher parity distribution seen among these women. 42 43 44 CHAPTER V INDUCED ABORTION Until recently, Romania was the setting of the most rigorously enforced pronatalist policy among all the communist countries of Central and Eastern Europe (David, 1992; Stephenson et al, 1992). A restrictive law, issued in 1966, reversed the legal status of abortion decreed in 1957 and permitted modern contraceptive use and induced abortion for only very limited medical and social reasons, and for women over age 45 (lowered to age 40 in 1973) or who have at least five dependent children . After 1984, the age limit for an induced abortion was raised again to 45 years and new measures to enforce the law were introduced (monthly monitoring of women of reproductive age, investigation of all spontaneous abortions, tight police surveillance of all gynecological wards, prison terms for women who confessed to having illegal abortions and loss of license, confiscation of property and imprisonment up to 12 years for physicians who performed illegal abortions). This situation of fear of punishment, distrust and suspicion forced women to take desperate measures to end unintended pregnancies (self induced abortion or procedures performed by lay persons) and to stay away from hospitals if they had medical complications. Although the prevalence of illegal abortions is impossible to assess, the dramatic effect on women's health was obvious to government officials but concealed from the public for many years. The true scope of the impact this policy had on reproductive health came to worldwide attention only after the December 1989 revolution and the change of government. During the last decade (1979-1989), Romania had the highest maternal mortality rate in Europe, a rate ten times higher than that of any other European country, and most of these maternal deaths were abortion-related (Stephenson et al., 1992). The magnitude of abortion complications is difficult to quantify but unofficial estimates suggest that nearly 20% of the 4.9 million women of reproductive age are thought to have impaired fertility (UNFPA 1990). The high number of unwanted pregnancies resulted in children abandoned in overcrowded orphanages by families who had been too frightened to attempt an illegal abortion, but who were too poor to afford to raise their child, was another shocking disclosure (Nachtwey, 1990). The dramatic experience of Romania has proved once again how reproductive health can be negatively affected through restrictive laws. On 26 December 1989, during the Romanian revolution, the restrictive law was revoked after public pressure was applied on the interim government. Abortion became available on request through 12 weeks of pregnancy, and the requirement that it be approved by a medical committee was eliminated. The previous legal provision to provide abortions up to 24 weeks in the cases of rape, incest, and endangerment of the woman's life if the pregnancy were to be 45 continued, was maintained. Clinics were inundated by women seeking abortions. Consequently, the legally induced abortion rate reached the highest level in the world - almost 200 per 1,000 women aged 15-44 in 1990-1992 (Ministerul Sanatatii, 1993). This corresponds to an abortion ratio of almost three induced abortions for each live birth for the same period (Ministerul Sanatatii, 1993), and to a total induced abortion rate (TIAR) of 3.4 abortions per woman (based on age specific abortion rates-see Table 5.2.1). Despite a spectacular decline, from 170/100,000 live births in 1989 to 60/100,000 in 1992, the maternal mortality rate remains the highest in Europe. 5.1 Induced Abortion Levels and Trends Most Central and Eastern European countries have a long history of reliance on abortion which was legalized before modern contraceptive methods were fully developed. Even after modern contraception became widely used in the West, these countries continued to rely on traditional methods of contraception and on abortion since modern methods were not readily available. Romania, in particular, had little exposure to modern contraceptives, which were neither locally produced nor imported. Importation of condoms and spermicides was officially prohibited in 1985 and other modern methods were never considered among imports. Insertion of IUDs became illegal. Conversely, abortion levels would be expected to be inversely related to fertility levels for the same period. But, as already mentioned, the vast majority of abortions performed before 1990 were probably never reported and official data on abortion were grossly underestimated. Even after abortion became legal, official statistics do not appear to be accurate. The best example is represented by the parallel decline of fertility and abortion levels in the absence of any significant change in the trend of modern contraceptive use (see Figure 5.1). Before examining fertility differentials by characteristics of women and trends over time in both Chapter IV and V, we compared the level of reporting of pregnancy outcomes in the survey with national counts provided by official statistics (Comisia Nationala Pentru Statistica, 1993B). This step was essential, not only for analyzing determinants of fertility and abortion, but also in interpreting contraceptive failure rates that depend on complete reporting of pregnancies (Jones and Forrest, 1992). Figure 5.1 displays a comparison of the numbers of induced abortions and live births estimated from survey data and data from the Ministry of Health Reporting System for 1988-1992 (Ministerul Sanatatii, 1993). Expansion factors based on the sampling fraction for each survey domain were used to convert the survey results into national-level estimates in order to make comparisons with the external data. 46 Whereas in 1988-1989 the number of abortions from both sources is almost identical, the survey estimates are lower for 1990-1991 but higher for 1992 and the first half of 1993 (1993 data not shown). The decline in official statistics after 1991 might be explained, in part, by the recent opening of private clinics that perform abortions and do not report to the Ministry of Health. On me other hand, the level of reporting in the survey, for abortions occurring in 1992 and 1993, may have become more complete as the negative implications of the previous illegality of abortion have faded into the past. Also, recall of more recent events has probably contributed to better response on abortions occurring in 1992 and 1993. Overall, for 1990-1992, is estimated that 81% of abortions reported by official sources were also reported in the survey. However, reporting in the survey may actually be greater than 81 % since some of the difference between abortion reporting in the survey and official 47 statistics may be due to double counting of an unknown magnitude in the official statistics.* Since the official reporting system in Romania has some overreporting built into the system and has recently been subject to an unknown amount of underreporting, we did not attempt to adjust the survey estimates. Table 5.1.1 shows that the majority of women who had abortions in 1990-1992 were aged 20- 34. Of the estimated 729,613 abortions in 1992, 28% were among women aged 20-24, 25% among those aged 25-29 and 26% among those aged 30-34. All abortion rates among these age groups have increased. Only 7% of the abortions in 1992 occurred among women less than 20 years old but both the rate and ratio per known pregnancies had substantially increased, by 76% and 52%, respectively, compared to 1990 levels. *In Romania, health care services are provided through predominantly state subsidized, "neighborhood type" clinics, and services are generally free of charge if accessed through the proper administrative steps and guidelines. If patients want to bypass the neighborhood clinic or the referral process, health care is not free and can be very expensive. Abortion, however, is not subject to these regulations and can be obtained in any hospital without referral, as an outpatient procedure at a standard cost equivalent to 5 % of the average monthly salary. If, for any reason, postabortion care has to be extended overnight, no additional costs will be charged. 48 Abortion ratios in Table 5.1.1 represent the percentage of known pregnancies (excluding miscarriages, stillbirths and ectopic pregnancies) terminated by abortion and were calculated by age of the woman at the time of pregnancy termination for abortions and at the time of delivery for live births. The ratios were lowest among teenagers in each year followed by women aged 20-24. Still, almost half of known pregnancies to teenagers ended in induced abortion as well as 60% of known pregnancies to 20-24 year olds. The abortion ratios increase with age and reach 80% or higher levels for women over age 30. These findings suggest that Romanian women complete their desired family size at younger ages after which most pregnancies are intentionally terminated, as described in Chapter IV. Although the benefit of permanent methods of contraception for these women is obvious, no efforts have been made to promote tubal ligation and male sterilization is virtually unknown. Less than 4% of fecund women in union who did not want any more children expressed interest in surgical contraception indicating that an information campaign would be needed to explain the benefits versus risks of permanent methods. Table 5.1.2 displays the percent distribution of induced abortions performed in 1990-1992 by number of prior induced abortions and by number of prior live births. 49 The proportion of repeat abortions rose rapidly after legalization. In 1990, slightly less than half of the abortions performed were repeat abortions (47%), and in 1992, this proportion rose to 60%: 26% were second abortions, 21% were preceded by two or three pregnancy terminations and 13% were preceded by 4 or more abortions. This rapid increase relates to the fact that if more women recently had an abortion, more are at risk of a repeat abortion, and is likely to continue especially if pre or postabortion counseling remains virtually nonexistent. After abortion became legal, the proportion of repeat abortions was lowest among women aged 19 or younger and increased rapidly with age. Women aged 35 years and over have the highest level of repeat abortions, especially of fourth or higher order; almost 32% of them have had at least three other procedures before their last abortion. The pattern of abortion utilization by parity does not show a clear trend between 1990-1992. With the exception of the increase of 26% in abortion procedures obtained by childless women in 1992 compared with 1990, me percent distribution by number of children born alive shows little variation. Abortions obtained by childless women represent only a small fraction of abortion procedures performed between 1990-1992. Most procedures were obtained by women with one and two children (25% and 38%, respectively). The percent distribution of abortion by parity is heavily influenced by age. Young women tend to obtain abortion when they are childless or have one child (82% of adolescents and 61 % of women aged 20-24). Women older than 35 have at least one child when they obtained abortions and most of them have two or more children. This provides additional indirect evidence that, with the second livebirth, childbearing is considered completed for most women. Parity specific abortion ratios per 100 known pregnacies for the same period of time (1990- 1992) are shown in Table 5.1.3. 50 The lowest ratio in each year is found among women with no prior live birth. In 1992, the most recent complete year for which the parity specific abortion ratio could be calculated, there is a notable increase in the abortion ratio. Almost one third of pregnancies experienced by childless women ended in induced abortions in 1992. The ratio of pregnancies which end in induced abortion more than double for women with one child and levels are higher as parity increases. The abortion ratio is highest at parity two (91% in 1992) which coincides with information recorded in the pregnancy history on desired fertility. Beyond two children, additional births become unacceptable to most Romanian women. The decline of the abortion ratio after parity three reflects a concentration of women, mostly in rural areas, who desire larger families and who are overrepresented in the high parity group. However, there is also a recent trend toward more pregnancies terminated in induced abortion among these women and almost three-fourths ended their pregnancies with induced abortions. 5.2 Induced Abortion Differentials Evidence that fertility decline in Romania is mainly achieved through the use of induced abortion was first brought to worldwide attention in 1958-1966, when, after abortion become legal, the total fertility rate dropped from 2.8 to 1.8 births per woman (Demographic Yearbook, 17th edition). The same pattern is noted after the recent liberalization of abortion. To better estimate the impact the use of induced abortion has had on fertility, we study differentials in induced abortion rates for the same three year periods and for the same women's characteristics used in the analysis of fertility (see Chapter IV). Table 5.2.1 shows that the highest abortion rate per 1,000 women by age group, in both periods (82 and 209 per 1,000), occurred among women aged 25-29, followed by rates of 65 per 1,000 and 167, respectively, among women aged 30-34. All but one age specific abortion rate is much higher in the most recent period. The age specific abortion rate for women under age 20 had tripled, from 10 per 1,000 in 1987-1990 to 32 per 1,000 in 1990-1993. The rates among women aged 20-34 had increased by 150% and by 50% among women aged 35-39. However, among women aged 40 or older, the abortion rate declined by 25%. Overall, the TIAR for all women doubled from 1.7 abortions per woman for the period 1987-1990 to 3.4 abortions for 1990-1993. A comparison of age-specific marital induced abortion rates reveals that induced abortion rates for married women were higher than those for all women in both periods of time (2.1 abortions per woman and 4.6, respectively) and, by implication, higher than those for unmarried women. These results are consistent with another finding that only 5% of pregnancies are terminated before the date of first union, and illustrate that abortion is primarily associated with married women in Romania. Since most women are married by age 25, marital abortion rates differ little from abortion rates for all women aged 25 and above. 51 There was a notable difference in fertility (see Table 4.3.1 and Table 5.2.2) and abortion rates between Bucharest and other urban and rural residents. On average, women residing in Bucharest have one child less and one abortion more then rural women in both periods. The highest increase in abortion rates occurred among young urban residents. Both fertility and induced abortion rates are inversely correlated with education level. The least educated women consistently reported the highest rates of abortion; the total abortion rate for these women more than doubled, reaching almost five lifetime induced abortions per woman after the change in legislation. The highest increase in abortion rate was experienced by the least educated women aged 20-24. Induced abortion levels are also inversely related with socioeconomic status in both periods. Women with low and middle socioeconomic status have almost one abortion more than women with high status. However, in the most recent period, the rate for women with high socioeconomic status is almost three times higher than before the change in legislation. 52 5.3 Reasons for Abortion Additional information on the last four abortions performed since January 1988 were recorded in a detailed abortion history which includes questions about reason for abortion, weeks of gestation, abortion procedures, abortion complications and sequelae and partner's attitude toward abortion. Data were collected starting with the most recent procedure in an attempt to minimize recall biases. The data gathered through this approach include almost exclusively legal abortion, which predominated after December 1989. Of 2,523 abortions which were reported to have occurred since January 1988, 93% were recorded in the abortion history. The remaining 7% were experienced by women with more than four abortion procedures in this interval. Most of abortions recorded in the pregnancy history (92%) occurred after the restrictions were lifted and almost all (98.5%) were legally induced abortion ("on request" or for medical reasons). This contrasts with the situation in 1988-1989 when two thirds of abortions were self reported as illegal abortions. 53 Table 5.3 shows that, after December 1989, 67% of abortions were performed for limiting or spacing childbearing, 20% for economic or social reasons (low income, crowding, fear of losing their job), 4% for partner related reasons (out of wedlock pregnancy, partner did not want a baby, separated from partner) and 4% for medical reasons (concerns that pregnancy was threatening the woman's health, fetal indications). 54 The use of abortion for spacing or limiting childbearing is directly correlated with woman's age and parity and inversely correlated with education attainment; this reason was more often claimed by women residing outside Bucharest. Socioeconomic reasons were mentioned more often by women who reside in Bucharest, where life is more expensive and adequate housing is an increasing problem, women under 35 years of age and women who didn't attain postsecondary education. Partner related reasons were more common among childless women (23%) and women under 20 years of age (12%); women with the highest level of education are also more likely to report these reasons (8%), presumably because they postpone marriage until after graduation from college or university. Health related reasons increase with education level and are more often reported by the youngest and the oldest women; Bucharest residents are more concerned that pregnancy would affect their health than their counterparts residing outside the capital. Overall, every year after abortion became legal, an increasing number of abortions were performed to regulate fertility and for socio-economic reasons. The other reasons do not show any significant trend. 5.4 Provision of Abortion Services With the repeal of the restrictive abortion law, the previous regulations requiring abortions to be performed after waiting periods and with approval of a special abortion commission were removed; overnight hospitalization (free of charge) was no longer mandatory. Abortion became an outpatient procedure (excluding patients hospitalized for complications) performed only in hospitals and abortion fees were symbolic. The requirement to restrict abortions beyond 12 weeks' gestation limit (excepting medical and juridical reasons) was maintained. At the end of 1990, nonhospital abortions also became legal. The official payment for an abortion procedure is entirely covered by the patient and has increased several times since December 1989, reaching about 5% of an average monthly salary in 1993 (10% or more for procedures performed in private practice). In addition, women usually have to make unofficial payments to medical personnel. After the change in legislation, most abortions have been performed in hospital facilities (93%) with only 7% in private cabinets or clinics. Each year, however, more abortions have been performed by private practitioners (11% in 1993) which may contribute to the decline in the number of abortions reported by MOH statistics. Almost all pregnancies 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. The vast majority of abortions (83%) were reported to be performed between 7 and 9 weeks of gestation, 8% under 7 weeks, 8% at 10-12 weeks and only 1% were reported as second trimester abortions. Numbers are too small to draw any statistical 55 conclusions but late abortions are inversely correlated to woman's age, number of prior abortions, education level and are more likely to occur in rural areas. Second trimester abortions constitute less then 1% of outpatient hospital procedures, 3% of procedures performed in private practice and 13% of those self induced or induced by a lay person. Abortions by suction curettage (vacuum aspiration: VA) were available immediately after the change in legislation as a result of equipment donated through humanitarian aid. VA is the safest and the easiest method of induced abortion in the first trimester. It requires either a manual or an electric suction device and, in the first weeks of pregnancy, allows "mini- abortions" without anesthesia and dilatation of the cervix. However, the international agencies could not provide enough equipment to handle the increased number of abortions, which are mostly performed by dilatation and curettage. Moreover, training in using the new method was not provided throughout the country. Many gynecologists, who were using only the traditional D&C (dilatation and curettage) for a long period of time, are either reluctant to use VA or tend to complete it with unnecessary dilatation and extensive sharp curettage. Under the Health Rehabilitation Project financed by the World Bank loan, provisions have been made to provide VA equipment to eleven FP referral centers. However, by the time the survey was concluded, most of the referral centers had not yet received these equipment. Thus, the traditional sharp curettage method was the main method used, regardless of the gestational age. Overall, more than 90% of pregnancies were legally terminated by D&C and only 9% by suction curettage. None of these abortions was performed by manual VA. Suction methodology was more available in Bucharest where 22% of pregnancies were terminated using vacuum aspiration and less available to rural residents (only 4% of their abortions were performed through suction curettage). 5.5 Abortion Complications More than two-thirds of the induced abortions that occurred before the change in legislation were illegal procedures associated with a high risk of postabortion complications. Figure 5.5 shows that 21% of illegal abortions reported in 1988-1989 were associated with early or late complications. This is probably a conservative estimate since more than 90% of illegal abortions were induced outside medical settings and less than 40% were completed with a D&C. One percent of illegal abortions required hysterectomy for severe complications. The rapid decline in illegal abortions (only 1.4% of abortions were reported as illegal procedures after December 1989 and the trend is toward a steady decrease) is associated with a tremendous reduction of abortion complications, both early and late. However, legally induced abortions are associated with a certain risk of postoperative complications, whose incidence and severity is strongly correlated with age of gestation, surgical procedure and operator's skills, type of anesthesy and preexisting pathology (Henshaw, 1990). 56 Overall, 9.2% of the legal abortions reported after December 1989 were followed by immediate complications (7%) or late sequelae (2.2%). Almost 16% of these legal abortions were treated with antibiotics for three or more days and 3% required hospitalization for early complications. Most of the early complications involved heavy or prolonged bleeding (60%) or pelvic infection, with or without fever (30%); less than 1% were perforations of the uterus. About 40% of complicated abortions required a second curettage. Excepting uterine perforation, it is difficult to asses 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 are followed by late complications. More than a half of immediate complications required one or more nights hospitalization and 15% were associated with late sequelaes (pelvic inflammatory disease, pelvic pain, Asherman syndrome, irregular bleeding). Figure 5.5 also shows a disturbing tendency toward a higher annual incidence of both early and late complications associated with legal abortions even if the differences are not statistical significant (from 8% in 1990 to 11% in 1993). This trend is particularly puzzling when the mean gestational duration for legal abortions had decreased and the percentage of pregnancy terminated by suction curretage had doubled (from 5% in 1990 to 11% in 1993). 57 5.6 Abortion Mortality It is believed that the most accurate maternal mortality statistics for Romania were available during the period when the restrictive abortion legislation was enforced. Essentially based on information reported in death certificates (were deaths were coded using the 8th and later the 9th revision of the International Coding of Deaths), these statistics were improved by detailed investigations of all unexpected deaths of women of childbearing age, including coroner reviews (Rochat, 1991). 58 The levels of maternal mortality dramatically reflect the consequences of outlawing abortion and contraception. In the first ten years after the restrictions on abortion were enacted, a 5-fold increase in abortion related deaths was recorded and 99.3% of these abortions were classified as illegal (Rochat, 1991). From 1980 to 1989, the abortion related maternal mortality rate (MMR) fluctuated between 112 and 148 maternal death per 100,000 live births, a level eight times higher than before the restrictive legislation was enacted, (Figure 5.6). The effect of switching from the use of illegal, unsafe abortions to legal abortions was reflected in the drop of the MMR, beginning in 1990. After many years of high rates of maternal mortality, more than 85% abortion-related, the MMR decreased between 1989 and 1992 from 170 to 60 per 100,000 live births, a decrease entirely due to the 60% decline in the abortion-related deaths. Even with this decline, induced abortion is still the first cause of maternal death in Romania, accounting for more than 60% of maternal mortality after December 1989 (69% in 1990, 62% in 1991 and 63% in 1992), mainly because of the continuing use of unsafe abortions. Since the use of illegal abortion was a routine for many women in the past and since nonmedical abortion providers might be more accessible, more affordable, or more familiar, the practice of illegal abortion is likely to continue, especially among women who seek abortion beyond the legal gestational limit of 12 weeks. 5.7 Abortion and Contraception Generally, induced abortion is used as a backup to contraceptive failure rather than a primary method of fertility control. In Romania, however, the limited availability of modern contraceptives, combined with a high level of misinformation and preconceptions concerning modern methods and a heavy reliance on traditional methods, has made induced abortion the primary method for averting unwanted births. This hypothesis is indirectly documented by the trend in pregnancy rates. Figure 5.7 displays the trends of annual pregnancy, fertility and abortion rates since 1988. The change of the total pregnancy rate (TPR) in the same direction as the total abortion rate (TIAR) suggests a high level of unintended pregnancy (almost always terminated through the use of legally induced abortions) and little impact of contraceptive practices on preventing these pregnancies, either because of low prevalence or because of high failure rates. The extremely high rate of abortion appears to be the principal determinant of the decline in fertility since no significant changes have occurred in the prevalence of contraceptive use or contraceptive mix (see Chapter VI). But, in the absence of effective contraception, abortion alone is an inefficient method to regulate fertility. The increased use of abortion as the primary means of fertility control has had an escalating effect on the pregnancy rate, mostly on mistimed and unwanted pregnancies, since it hastens the woman's return to the risk of conception through a shortened duration of pregnancy (from about nine months to about three months) and of the postgestational anovulatory period. 59 Increased use of abortion may also explain the slight increase seen in the use of withdrawal and calendar methods, which would not be expected to be affected by the policy change. Since a pregnancy resulting in abortion returns a woman to risk of conception more quickly than does a pregnancy carried to term, it also increases the time during which she has the opportunity to use contraception. Since women have continued to use mostly traditional methods, which have very high failure rates (see Chapter VI), more unintended pregnancies occur, and consequently, more abortions take place. 60 CHAPTER VI CONTRACEPTION After revoking the restrictive law on abortion and contraception at the end of December 1989, Romania was confronted with a difficult mission: to establish a comprehensive family planning program tailored to manage both me burden left by more than two decades of rigorously enforced pronatalist policy, and the recent economic and political changes. During the fallen regime, contraceptive and sexual education were generally unavailable and importation and sale of contraceptives was forbidden; traditional contraceptive methods, with their high failure rates, were almost the only means to avoid unintended pregnancies. Legal abortions were severely restricted. In a society which traditionally relies on induced abortion to control fertility the result of restricting abortions was particularly devastating; unsafe, clandestine abortions performed on a large scale were followed by a wide array of complications including maternal deaths which reached me highest level in Europe. The availability of legal abortion dramatically improved women's health and their reproductive rights, but the newly created family planning program has not made much impact since suspicion and ignorance regarding modern contraception persist. The prevailing public opinion, that modern contraceptives are harmful, is shared by many health care professionals, who are reluctant to accept and promote these methods due to their lack of family planning training and limited access to updated medical literature (David, 1992). The insufficient infrastructure, absence of family planning logistics and managerial skills, and shortage or uneven distribution of contraceptive supplies, are other critical factors that have diminished the impact of the newly founded program. As stated in the objectives, the survey was designed to provide planners and program managers with a nationwide snapshot of contraceptive prevalence, awareness and opinions. In order to assess this, all women were asked, in reference to each specific contraceptive method if they have ever heard about it, from whom, if they know where to get it, and which method have they ever used and are currently using. This chapter presents data primarily concerning women with a partner or husband at the time of the survey, who are referred to as women in union. 6.1 Knowledge of Family Planning Methods and Their Sources Since family planning was officially banned in Romania for so many years and a systematic campaign was mounted to misinform me public about modern contraception and their benefits, it is very likely that lack of knowledge, mistrust and fear of these methods to be a major obstacle to their use. Thus, an important objective of RRHS was to explore the current level of knowledge of family planning methods and their sources after more than three years since the restrictive legislation has been reversed. 61 Table 6.1.1 shows that almost all currently in union women as well as previously married women know of at least one method of family planning, either traditional or modern method (98 percent). With the exception of unmarried women, whose awareness of traditional methods is much lower than that of modern methods, knowledge of traditional methods are virtually the same as that of modern methods. The most widely known method is the condom. Condoms had never been banned but were essentially unavailable after 1985 when both imports and local production were ceased. It is followed by the pill, IUD and female sterilization known among all women by 79 percent, 71 percent, and 56 percent, respectively; however, unmarried women are less likely to have heard of the last two methods than married and previously married women. The least known modern methods are the diaphragm, vasectomy and injectables. Not all women who have heard about a modern method know where they can obtain it and the gap between knowledge of any modern method and knowledge of their sources (about ten percentage points) is not significantly influenced by marital status; however, the gap varies greatly by specific methods, especially for the more widely known methods, reaching 29 percentage points for the 62 pill, 25 percentage points for condom and 20 percentage points for IUD. Is worth noting that unmarried women are more likely to know a source of condoms or pills compared with currently or previously in union women since their gap between knowledge of these methods and their source is narrower (20 percentage points for pill and 17 percentage points for condom). Table 6.1.2 summarizes the findings on contraceptive awareness by residence for women currently in union. Almost all women currently in union have heard of at least one contraceptive method (98%) and the vast majority recognize at least one modern method (95%). Unfortunately, how much and what they know, particularly about modern methods, is impossible to assess using these questions. Additional questions asked to explore attitudes and opinions toward modern methods (see Chapter VIII) show a high level of misinformation and preconceptions, contributing to their low prevalence. 63 There is little difference in the level of overall contraception awareness by residence, even when it is classified into traditional and modern contraception. The urban level is only 2 to 3 percentage points higher than the rural level and the gap becomes slightly larger for modern methods (6 to 7 percentage points). However, the level of knowledge of specific contraceptive methods varies. Overall, the more widely known methods are withdrawal (91%), especially for other urban residents (94%), and the condom (90%), better known among residents of urban areas, including Bucharest (96%). The calendar method is the third (84%), but is less well known in the rural areas (74%); IUD and pills are known by almost 9 out of 10 urban women, but only by 66% of rural women. Sixty-five percent of women have heard about tubal ligation and this proportion increases to 75 % among other urban women. The least known modern methods are injectables, vasectomy and the diaphragm, known by 15, 13, and 9 percent, respectively; the level of knowledge for these methods is even lower in rural areas. 64 Table 6.1.2 also shows that a large majority of women in union know of at least one source of family planning (85%). A greater percentage of women in urban areas know a possible source of family planning than women in rural areas (90% versus 75%). The percentage who know a source for condoms, IUDs, and pills is 61%, 56% and 48%, respectively. Less than 60% of the women were able to correctly identify where to obtain a tubal ligation. Very few women know where to get diaphragms and injectables or where a vasectomy can be performed. For the most widely known contraceptive methods, there is a serious gap between awareness of the method and knowledge of sources, ranging from 8 percentage points for tubal ligation to 24 percentage points for the IUD, and over 28 percentage points for the pill and condom (see also Figure 6.1.1). This discrepancy is most puzzling for Bucharest, because many educational efforts and family planning provisions have been directed there. In Bucharest, differences of as much as 33 percentage points between pill awareness and knowledge of a source and 31 percentage points for condom are difficult to explain. 65 Excluding women with no or only primary education, the level of knowledge of any method, any traditional or modern methods and sources for modern methods is not significantly different for better educated women (see Table 6.1.3 and Figure 6.1.2). The least educated women have a lower level of awareness of any specific method, including traditional methods, and they are much less likely to know a source for any modern method than women with some secondary school or higher education. The gap between awareness of any modern method and knowledge of a source for it progressively narrows with the increase in education level and almost disappear for women with the highest level of education. For most of modern methods, the ascending pattern of awareness and of knowledge of source with the increase in education becomes more obvious and a wider gap between the least educated women and those with higher education occurs. For instance, less than 60% of women with primary or no education have ever heard of IUD or pills and only one of three know where these methods can be obtained, whereas almost all women who completed the high school are aware of these methods; injectables, vasectomy and diaphragm are basically unknown methods. 66 Overall, the major source of information about any contraceptive method was a female friend or acquaintance (45%), followed by mass-media (19%) and health care providers (10%). Almost 10% have first heard of contraception from their partner, 5% from a relative and only 4% mentioned their mother as the first source of information. Thus, almost two thirds of all women first heard about a contraceptive method outside of a medical or educational source so the quality of these information is uncertain. Since family planning was prohibited during Ceausescu pronatalist policy, even education programs focusing on contraception and medical advice offered at that time could represent biased sources of information for most modern methods. Even after 1990, when uncensored publications became available, mass-media have played a minor role in contraceptive educational efforts due to financial constraints, lack of specialists able to educate the public about family planning in non-technical terms, and little interest in health issues (compared with political and economical topics suddenly freed after decades of rigorous censure). Also, because of limited access to family planning literature and lack of experience with modern contraceptives, many health professionals might still be a source of misinformation and negative perceptions about contraception. 67 The proportion of women who named as a primary source of their contraceptive awareness either mass-media or a health care provider increases with education level -almost 30% and 20%, respectively, for women with college- and is higher for urban residents. Is also higher when the information concern modern methods compared with traditional methods (Figure 6.1.3). For example, almost a third of women who have heard of tubal ligation and 26% of women who have heard about IUDs mentioned a medical provider or a pharmacist as the first source of information but only 3 % of women who know about the calendar method got their information from a health professional and 8% from mass-media. Mass-media was a better source of information concerning condoms and pills (25% of women who know about condom and 23% of those who have heard about the pill named this source) and is the primary source of information for the few women who are aware of vasectomy, diaphragms, and injectables. 68 6.2 Current Contraceptive Prevalence and Its Trend At the time of the survey 41% of all reproductive age women reported using a contraceptive method. For women currently in union contraceptive prevalence was 57 percent, 43% using traditional methods and only 14% using modern contraceptives. Figure 6.2.1 shows that contraceptive use (especially of modern methods) among women who are not currently in union is almost negligible. As can be seen in Figure 6.2.2, the most prevalent method of family planning is withdrawal (34%) followed by the calendar method (8%). As for modern contraception, used only by 14.5% of respondents, IUD (4%), condom (4%) and pills (3%) are the most common methods. Less than one percent of women use spermicide, mostly tablets and suppositories, and only 0.3 percent are using injectables, diaphragms or other modern methods. Overall, only 1.4% of women currently in union have been contraceptively sterilized and not one respondent said that her partner has had a vasectomy. 69 70 Urban residents (see Figure 6.2.3 and Table 6.2.1) have a slightly higher contraceptive prevalence than rural women, but more significant is the variation in prevalence of specific contraceptive methods by residence. Traditional methods prevail in all subgroups. Withdrawal is the most prevalent family planning method for both rural women (42%) and urban women (31%). The calendar method is the second most heavily used (8%), especially in urban areas. Urban residents have the highest prevalence of modern methods (17%). The proportions using specific modern methods vary, but are very low. For both urban and rural areas, the IUD is the most frequently used modern method, followed by condoms and the pill, but there is no significant difference in use of these methods. Contraceptive prevalence also differs slightly by region. Residents of Transylvania have the highest contraceptive prevalence rate (67%), but this is based on a heavy reliance on withdrawal (44%). In Bucharest, only 53% of women are using a contraceptive method but they have the highest use of modern methods. It is also the only region where the calendar method is used (16%) equally with withdrawal (17%). Both Moldova and 71 Vallachia (Muntenia) have low contraceptive rates, 52% and 53%, respectively, with high prevalence of traditional methods. As mentioned, modern methods are the most prevalent in Bucharest (20%). The higher usage of condoms is also notable (8%) followed by IUD usage (6%). This might reflect better availability but may also be associated with education level, since more than 50% of respondents in Bucharest had completed secondary or higher education. The prevalence of modern methods in Transylvania (19%) is essentially equal to Bucharest, with the IUDs and pills used by the highest proportion of women in the country. Moldova and Vallachia have the lowest prevalence of modern methods--9 and 10 percent respectively. Younger and older women in union are the least likely to be using contraception than are women at the peak of their reproductive life (see Table 6.2.2). The highest contraceptive usage is among women 30-34 (69%) and the next highest among women aged 25-29 (66%). These age groups also have the highest modern methods usage, especially IUDs and condoms. 72 There are important differences in the rates and characteristics of contraceptive use according to the number of living children (see Table 6.2.3). Contraceptive use rapidly increases with the number of living children, reaching a peak among women with two children (67%) and declining thereafter. However, the reliance on traditional methods compared with modern methods consistently increases with the number of living children. The ratio of traditional methods to modern methods is 2:1 for childless women, 3:1 for women with 1-3 children and 4:1 for women with 4 or more children. Only 32% of childless women in union are using contraception and only one third of them are using a modern method, mostly condoms or the pill. For women with one or two children, only one fourth use a modern method; IUD usage is most prevalent (6% and 5%, respectively). Almost all women who have been sterilized have at least two children. 73 Contraceptive use steadily increases with increasing education level (Table 6.2.4). Women in the lowest education category have the lowest rate of contraceptive use (42%), whereas women who attended college or postsecondary school have the highest contraceptive prevalence (71%). Traditional method use prevails even for better educated women, but the ratio of traditional/ modern contraceptive use decreases from 5 to 6:1 for poorly educated women to 2:1 for women who have completed secondary school or higher education. Calendar method use is strongly correlated with education, increasing from less than one percent for the least educated women to 21% among the most educated group. Withdrawal, the most prevalent method for all the subgroups, does not show any consistent pattern by education. The use of modern methods rapidly increases once a woman has a secondary complete or higher education. The IUD, the condom, and the pill are the methods preferred by women who completed high school, whereas condom is the modern method most used by women with a higher education. 74 Table 6.2.5 summarizes the contraceptive prevalence by background characteristics and underlines that the prevalence rate for modern methods is always lower than for traditional methods, never exceeding 28%. It also shows that among current users, three quarters are using either withdrawal or the calendar. For all demographic characteristics shown, modern contraceptive use for current users never exceeds the prevalence of traditional methods for any specific subgroup. Only for women classified as having high socio-economic status (47%), who live in Bucharest (38%), or who have postsecondary education (34%), does the use of modern methods exceed one third of the total use. 75 The study of contraceptive prevalence before and after the repeal of the restrictive law shows little change in contraceptive use (Figure 6.2.4). Moreover, the slight increase seen is parallel for both traditional and modern methods, despite the efforts of the new government to promote modern contraceptive use. It is noteworthy however, that the increase in modern contraceptive use is almost entirely due to increase usage of IUDs and condoms whereas the pill usage does not show any change (Table 6.2.6). 76 These data are based on the month-by-month contraceptive experience recorded for all women who ever used a contraceptive method in the last five years. Since equally detailed month by month history of marital status was not obtained, annual contraceptive prevalence rates for women in union cannot be computed. 6.3 Source of Contraceptive Methods and Their Cost In order to assess source of contraceptive methods, the RRHS included questions about the place where current users of supplied contraceptive methods obtain their methods. Since the family planning program was only recently instituted by the government and nongovernmental organizations, and since a nationwide contraceptive logistics system has only recently been outlined and is not yet functional, information regarding sources of contraception is of great interest. Pharmacies, either public or private, are the most important sources of contraception; they provide 38% of me women in union who are currently using a modern method of contraception. Because pharmacies are the subject of a rapid process of privatization, it is very difficult to differentiate between public, private and mixed ownership status. The next most important source, supplying 31% of current users, is the public sector through 'contraceptive cabinets' set up mainly in hospitals, but also in polyclinics and dispensaries. Surprisingly, the third most important source of contraceptives is the "black market" which supplies almost 17% of users. The private sector and the principal family planning nongovernmental organization (NGO), the Sexual Education and Contraception Society (SECS), supply only 4% and 1% of users, respectively. Other sources, such as friends, relatives, partners, supply as much as 6% of users (see Table 6.3). The source varies greatly according to the particular contraceptive method used. Pharmacies are the principal provider for condoms and pills (supplying 59% of condom users and 42% of pill users) and the second provider for IUD users (19%). The government's family planning network provides most of the IUD users (59%) but supplies only 10% of pill users and very few condom users (1%). The private sector accounts for 13% of IUD coverage, 2% of pills and no condoms; SECS is a less likely source for all these methods supplying 3% of pill users, 2% of IUD users and less than 1 % of condom users. As to underline the deficiency in logistics management, the second most used source for condoms and pills (30%) is the black market. All tubal ligation were performed in governmental hospitals, the only settings fully equipped for such interventions; in Romania tubal ligation is often perform during another surgical intervention which requires laparotomy (e.g. cesarean section) and the new techniques of minilaparotomy and laparoscopic sterilization are basically unknown. 77 There are hardly any significant differentials in the main source of contraception according to residence, region , education and socioeconomic level of the current users. Urban women are slightly more likely to obtain their method from pharmacies whereas a higher proportion of rural women got their method at the black market. The black market is also the second most important source of contraceptives, after pharmacies, for resident of Moldavia (31%), while the governmental sector provides only 20% and of these women. In Bucharest, one in two currently in union woman is getting her supplies from a pharmacy. Less educated women and women with low socioeconomic status are more likely to get their contraceptive supplies from governmental clinics or black market while about half of women with high education or socioeconomic status get their methods from pharmacies. Information about the cost of modern methods were obtained from two thirds of women in union currently using modern contraceptives. Almost 13% obtained their methods free of charge and 24% either were not asked (women with tubal ligation, since the intervention is mostly performed 78 in conjunction with other surgery), or they did not know the price, especially when their partner provided the method (24% of condom users, 10% of IUD and pills users). For those who paid for a modern method, the average cost was almost 2,000 lei for IUD, 650 lei for a cycle of pills and 60 lei for a condom (1,000 lei=$ US 1.00). The cost varies according to the source of supplies but given the small number of cases the differences are not significant. In general, pharmacies and governmental clinics charge similar prices for specific methods, while the private sector is more expensive and the black market is less expensive for condoms. Most of the contraceptive supplies available in Romania are purchased from UNFPA by the Ministry of Health (MOH) family panning program, a sub-component of the Health and Rehabilitation Project financed by World Bank. These supplies, however, are distributed through pharmacies and not through the government FP clinic. This explains why the pharmacies represent the second most important source of IUDs, which have to be purchased by women prior to insertion in a governmental FP clinic. The only methods generally available at the public clinic level are donations made by international NGOs or foreign pharmaceutical companies. Thus, the public sector is the only important source of free of charge contraceptive methods. Of the 13% women who currently use modern contraceptives and did not pay for them, more than a half received their method free of charge in a governmental clinic. When these clinics decide to sell some of their supplies (e.g. to cover educational activities), they generally charge a similar price as public pharmacies. With the expansion of privatization in Romania, supplies directly imported by private distributors have become a growing source of modern contraceptives sold in pharmacies. These methods are 4-5 times more expensive than those imported by MOH but are available in large quantities and various brand names. An increase consumer demand might increase competition between suppliers, possibly lowering the prices in the future. 6.4 Reasons for Not Using Contraception To better understand the low prevalence of modern contraception and the barriers to the newly created family planning program, all women were asked the primary reason for not using contraception. Moreover, women using a traditional method, were asked why they are not using a modern method, how they assess the effectiveness of their method, and whether they want to change their current method. Both nonusers and traditional method users, who desire to change the current method, were asked what method they would prefer. Table 6.4 summarizes the primary reasons given for not using contraception, by marital status. About half of nonusers report lack of sexual activity as the first reason; 95 % of never married women, 70% of previously married, and 5% of currently in union women give this reason. Almost one fourth of all nonusers and almost a half of women in union, maintained that they cannot become pregnant, either because they or their partner were told that they are infertile, or they tried to become pregnant for at least two years without success. 79 Seventeen percent of nonusers in union give a pregnancy-related reason (currently pregnant or trying to get pregnant) as the prime reason for not using contraception, 5% report difficulty getting pregnant, and only 4% are postpartum or breastfeeding. Fear of side effects is accounted by 4% of nonusers as the first reason for not using contraception. Only 5 % of women claim they never thought of using a contraceptive method and an equal number say that their partner opposes contraceptive use. Only 3% of nonusers in union says they don't use contraception because they prefer abortion to control their fertility. Only 1% of women perceive accessibility, availability or cost as the principal reason for not using a method. 80 6. 5 Nonusers and Traditional Method Users Table 6.5 displays the percent distribution of women currently in union who do not use any method or use a traditional method, by desire to use a specific contraceptive method, and by residence. Nonusers are slightly more likely to desire modern contraception than traditional contraception users, but the difference is not statistically significant (18% versus 16%). Residents of Bucharest appear to be more interested in using a modern method in both groups-25 % and 21 % respectively- but again the differences are not statistically significant. The most important finding is that fewer than 18% of non-users and less than 16% of users of traditional methods expressed a desire to use a modern method. Four out of five traditional method users do not want to change their current method. The desire for a specific modern method does not vary considerably among nonusers and traditional methods users except for the difference in potential sterilization use. Almost all nonusers who intend to use a modern method in the near future desire to use either IUD (45 %), 81 the pill (29%) or contraceptive sterilization (15%); for those who currently use a traditional method, the preferences are 44% for IUD, 38% for the pill and only 1% for sterilization. The hierarchy of their preferences do not change by residence. Users of traditional methods were asked how important were several reasons specified in the questionnaire in their decision not to use a modern method. Table 5.8 illustrates only the percentage of women who assert as very important or somewhat important the given reasons. Most women stated that fear of side effects, partner preference and little knowledge about modern methods are the major reasons in their decision not to use a modern method. About one-third cited the difficulty of obtaining modern methods or their cost. One-fourth acknowledged as an important reason that the doctor recommended the use of traditional methods. Only 12% considered their religious beliefs an important factor in their contraceptive decision. Table 6.5.3 shows the opinions of women in union using traditional methods comparing the effectiveness of their method versus the effectiveness of modern methods (e.g. the pill, IUD) by education. Unexpectedly, more than a half consider their method more effective (34%) or equally effective (29%) to modern methods and this belief is not affected significantly by education. These findings highlight the public's lack of correct information about modern contraceptives and women's trust in the traditional methods historically practiced in Romania to prevent pregnancy. Their trust in traditional methods is not justified if one considers the high failure rates associated with these methods (Table 6.6.1). 82 If modern contraception is to replace these practices and beliefs, more efforts must be targeted toward heightening public awareness through community education and patient counseling in family planning clinics. 6.6 Contraceptive Failure and Discontinuation Rates Contraceptive failure and discontinuation rates were calculated using information collected through a detailed month-by-month pregnancy and contraceptive use history in the last five years preceding the survey. 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, the rates could be seriously underestimated. In order to reduce this risk, we calculate failure and discontinuation rates only using segments of contraceptive use initiated after the abortion became legal, from January 1990 through June 1993 (we use this cut-off for all women, even through the history was extended up to the end of the year, to be sure that the respondents were aware of all the pregnancies occurring toward the end of observed period). Even taken these precautions, since the overall level of abortion reported in the survey for this time frame is actually 15% lower than that reported by official sources (see also Chapter V), the rates reported here are minimum estimates, and the true rates are probably somewhat higher than shown in Table 6.6.1. 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 who were using a contraceptive method during the observed period (January 1990-September 1993). Linking 83 together these probabilities, 12-month contraceptive discontinuation and failure rates can be calculated. They represent the proportion of users who stop using their method within the "first year" of use for any reason (discontinuation rate) or because they become pregnant while using the method (failure rate). "First year" of use refers to uninterrupted intervals of use of 12 months; 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 she had used another or no method. When more than one method had been used during any month, that month contraceptive experience is assigned only to the most effective of the two methods. Overall, almost 40% users discontinue their method use during the first year and one in four users experienced a pregnancy while been using a contraceptive method (Table 6.6.1). Discontinuation and failure rates vary considerably by contraceptive method used. About 40% of women discontinue the use of traditional methods after the first year of use; for both withdrawal and the calendar method, 30% result in method failure within 12 months of initiating use. Thus, the high discontinuation rate is accounted for by method failure (78% for withdrawal and 75% for calendar method). The condom also has a high failure rate of 21 % which accounts for almost half of the reasons for which this method was discontinued. The high failure rate reported for condom (higher than that reported in other national household surveys) might be explained through incorrect or inconsistent use, or through poor quality since a third of condom users were obtaining their method from uncontrolled sources (black market, friends, relatives, etc.). 84 The low failure rates at 12 months for pill and IUD are comparable with rates published in the literature (2.4% for the pill and 4% for IUD). Is interesting to note, however, that as many as 39% of pill users discontinue to use pills after the first year, despite the low failure rate associated with this method. As can be seen in Table 6.6.2, the experience of side effects or fear of side effects and doctor's recommendation to stop using pills account for more than a half of reasons of discontinuing pills use. The IUD discontinuation rate after first year of use is the lowest among all contraceptive methods (14.2%) and among women who stopped using the IUD, more than a half cited side effects and health concern as the main reason for discontinuing IUD use during the first year. The discontinuation rates in Table 6.6.1 and 6.6.2 are calculated using a single decrement life table analysis. Such a life table assumes, for example, that if the reason for stopping was the method failure, this is the only risk for discontinuing a method while the effect of other competing reasons for discontinuation is eliminated (discontinuations for other reasons are treated as censored observations). The resulting failure rate is called the gross failure rates and measure the risk of contraceptive failure that would be expected if failure is the only reason for discontinuing use. Another approach is to calculate net failure rates with a multiple decrement life table analysis which assesses discontinuation rates for a specific reason (e.g. failure) in the 85 presence of other reasons. The gross failure rate is somewhat higher than the corresponding net failure rate because, by eliminating the effect of other discontinuation reasons in a single decrement analysis, more women will be at risk of failing, so the failure rate will be increased (Trussel J., 1987). Nevertheless, the gross failure rate is a better approach in assessing contraceptive failure because it is not affected by the levels of discontinuation for other reasons which can vary between different populations and may distort the comparison of failure rates. Thus, the gross rate represents the underlying risk of failure in a population and may be safely compared among different population groups. In Table 6.6.2 the gross rates were separately calculated for method-specific discontinuation reasons other than failure. These gross rates are particularly useful when we want to look at separate reasons for discontinuing for different methods or if we want to compare each of them with the corresponding rates (i.e failure rates) in different populations or in the same population over time. Both failure rates and discontinuation rates can be affected by user characteristics, especially for methods with low inherent effectiveness or which are prone to inconsistent or incorrect use. Table 6.6.3 shows that both failure rates and discontinuation rates decline with women's age, regardless the method used. These findings may not reflect the true effect of age since the data are not adjusted for marital status and since coital frequency is an important confounder which declines both with age and marital duration. Another important factor, which can contribute to the age decline of these rates, is the increasing threat of subfecundity with age, given the increase in the risk of unintended pregnancies with age and subsequent termination of these pregnancies through unsafe abortions (of 600 subfecund women in our study, two-thirds are 35 years or older). 86 6.7 Intention to use contraception and induced abortion in the future All respondents were asked if they would use, would not use, or if they are not sure about using specific methods of birth control, including induced abortion. Tables 6.7.1 and 6.7.2 present only the percentage of women currently in union giving positive answers. The data shows that less than half would use any modern method some time in the future and 26% would consider using induced abortion as a means of fertility control (Table 6.7.1 ). 87 Women in Bucharest are more likely to say that they would use a modern method (57%) whereas women in Transylvania are more likely to use withdrawal (60%) and are the least likely to use induced abortion (18%). Interest in using a modern method or withdrawal is clearly associated with contraceptive experience; it is highest for current users and lowest for never users, with previous users between the two extremes. Current or previous contraceptive experience does also increase intent to use induced abortion in the future. Intent to use induced abortion is positively correlated with number of living children. This is not surprising since the wanted fertility rate over the past three years is 1.4 children per woman and more than 70% of women in union consider that the ideal family size is two children or fewer. But is startling that women with three or more children are more likely to use withdrawal then a modern method. Women whose last pregnancy ended in induced abortion are most likely to either want to use a modern method or continue to use abortion. Attendance at religious services does not significantly affect desire to use either modern methods or withdrawal but those who attend at least once a month are less likely to want to use induced abortion. Interest in modern methods increases with socio-economic status; more than half of women classified as having high socio-economic status stated they would like to use a modern method and are the least likely interested in withdrawal. Socioeconomic status is not associated with intent to use induced abortion in the future. Table 6.7.2 shows the future birth control preferences of women currently in union, by residence and education by current contraceptive status. Since contraceptive use status has proved to be an important variable in women's decisions about the future and since it greatly affects the choice of a specific contraceptive method and the reason for having an abortion, data are presented separately for users and nonusers. Overall, women residing in Bucharest and those who completed secondary school or higher education are more likely to want to use a modern method. Withdrawal appears to be the most favored method in both groups, regardless of the area of residence or educational level. However, the choice of withdrawal is inversely correlated with education among current users. Among modern methods, the IUD and the pill seem to be the most preferred future methods for both current users and nonusers and this preference consistently increases with education level. Urban women say they would be more likely to use the IUD and the pill then do rural women in both groups. For all methods, with the exception of tubal ligation and injectables, interest is higher among current users. The acceptance of abortion as a birth control method is not influenced by education level for either users (26% to 29%) or nonusers (20% to 27%), but varies by residence. Current users and nonusers who reside in Bucharest are more likely to rely on abortion. 88 89 90 CHAPTER VII WOMEN IN NEED OF FAMILY PLANNING SERVICES Another approach to asses the potential demand for family planning services, independent of that derived from direct responses of women in union regarding their contraceptive behaviors, is to define the contraceptive needs of women in relationship with their fecundity and stated reproductive preferences, regardless of their marital status. The total 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, 1991; Westoff and Ochoa, 1991). Estimates for the total demand and unmet need for contraception may vary from one survey to another if the criteria used in defining the terms or survey questions are not the same. The conventional approach used to calculate unmet need is to exclude women who are not currently in union, women who are currently using any contraceptive method, those who are temporarily not 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 (Westoff, 1988). By restricting the denominator to women in union, the percentage of women with unmet need of FP services is likely to be higher, since married women generally have a higher risk of unintended pregnancy and a higher demand for family planning; 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) who may be overlooked by policy makers. Moreover, the exclusion of current users of less effective contraceptive methods further narrows the estimated number of women with unmet need of more effective contraceptive methods. In countries with widespread use of traditional contraceptive practices, this approach masks the real need for more effective contraception. For instance, the unmet need for contraception in Romania according to the Westoff definition would be relatively low (11.4%) and would be inconsistent with the high rates of unintended pregnancy (more than two thirds of pregnancies which had occurred in the last three years were reported as unintended) and induced abortion (95% of the unintended pregnancies were ended in induced abortion). Therefore, in the context of Romania, an estimate of the "need for any or more effective contraceptive methods " would provide a more accurate picture of the need for family planning services. According to this estimate, women of reproductive age are in need of family planning services if: (a) they are fecund; (b) currently sexually active; (c) not pregnant or in postpartum 91 92 abstinence; (d) are not currently trying to become pregnant; (d) and are not using any or are using a less effective contraceptive method, regardless of marital status. Using this definition, the proportion of women at risk of unintended pregnancy is much higher. Table 7.1 and Figure 7.1 show that 39% of Romanian women of reproductive age and 55% of currently in union women are at risk of unintended pregnancy, compared with the classic "unmet need" estimate of 8% and 11%, respectively. According to the most recent census data, this percentage translates into more than 1.9 million women in need of any or more effective contraception, almost 93 % of them in union. This is probably a conservative estimate since currently pregnant women whose pregnancy was unintended were excluded from calculation of the "unmet need", regardless of the month of gestation and the likelihood they might terminate their pregnancy by induced abortion. Thus, the newly created family planning clinics are serving only about one fifth of women currently in union at risk of unintended pregnancy. 93 94 Overall, the unmet need for family planning at the time the survey was carried out was 39%. As Table 7.2 shows, the proportion of women in need of any or more effective contraception is higher among those living outside Bucharest, those currently in union, those older than 24 years of age, those with low level of education, those with two or more children and those classified as low or medium socioeconomic status. For each of the characteristics mentioned above, the lowest percentage in need can be seen in Bucharest and, with few exceptions, is higher for other urban areas and reaches a maximum level for rural areas. One exception worth noting is that one out of every ten never married women residing in Bucharest is at risk of unintended pregnancy which represents double the proportion in other urban or rural areas. Since most of these women are young adults, one possible explanation could be the higher percentage of premarital sexual experience reported by young adults in Bucharest (see Chapter XI). The same explanation may apply for childless women residing in Bucharest, whose need for any or more effective contraceptive methods is also higher. In rural areas, the proportion of women at risk of unintended pregnancy reaches the highest levels among those aged 25-34 years (66%) and those with two or more children (over 60%). 95 CHAPTER VIII REPRODUCTIVE HEALTH KNOWLEDGE AND ATTITUDES By the mid 1960s, the state had eliminated sexuality from public discourse. Sex education was not discussed in school and rarely at home. Movies and magazines were censored for showing nudity. Girls were conditioned to fear men, avoid pleasure and seek sex for purposes of procreation only. In a focus group study including fifty women of various ages and backgrounds, one respondent, a 28 year old teacher, explained that her sex education was reduced to statements from her father like "I'll break your neck if I find you with boys"(Baban and David, 1994). In the years since abortion and contraception have been legalized and pro-natalist laws repealed, most women who considered themselves to be at risk of pregnancy have largely chosen traditional methods or no method of birth control. As shown earlier (Chapter VII), the unmet need for effective contraception, including women not using any method and women using traditional, less effective methods, was 49.2%. As such, it is important to understand the attitudes and knowledge that surround family planning in Romania as well as the factors that may or may not affect a woman's reproductive heath decisions. Each respondent answered a series of questions regarding her knowledge and attitudes on several aspects of reproduction. These questions included opinions on the ideal family size, knowledge of the fertile period, opinions on the conditions under which abortion should be allowable, opinions about the efficacy, safety, and side effects of oral contraceptives and the IUD, the desire for further information on family planning, and attitudes about the role of women. The results of these questions should prove useful for developing and modifying elements of reproductive health education. 8.1 Ideal Family Size Respondents were asked what they thought was the ideal number of children for a young family in Romania. The ideal number or mean desired number of children in Romania as expressed by the survey respondents was 2.1 children; details are shown in Table 8.1. There is little variation in the mean ideal number of children by respondent characteristics shown in Table 8.1. With the exception of women who already have four or more children (mean=2.4 children), the mean ideal number of children varies from 1.9 to 2.2. The two children per family appears to be the consensus regardless of residence, ethnic group, education or socio-economic status. 97 98 99 8.2 Knowledge Of The Menstrual Cycle Due to the vacuum of information relative to sexuality and family planning, it was important to determine what type or level of information women had about basic concepts regarding fertility. Table 8.2 summarizes women's knowledge of the menstrual cycle, a common indicator for the level of sexual education. Each respondent was asked at what time during the menstrual cycle is a woman at the greatest risk of becoming pregnant. Fifty-four percent of respondents correctly said that the chance of pregnancy is greatest halfway between menstrual periods (Table 8.2). This proportion is practically the same as the 55 % found in a recent survey in the Czech Republic (Czech Republic Reproductive Health Survey-Final Report, 1995). Knowledge of the menstrual cycle was lowest among women who live in rural areas (42%), women under the age of 20 (27%) and also among never married women (37%), who are largely younger women. Knowledge was also quite low among gypsy women (17%) and women with only primary education (37%). Knowledge of the menstrual cycle increased sharply with increased education (from 37% to 84%) and socioeconomic status (from 38% to 72%). Women using natural family planning (rhythm), which depends on a woman/couple knowing when conception is the most likely to occur, have the highest level of knowledge (88%) of any sub- group. 8.3 Attitudes About Abortion As described in Chapter V, the rate of induced abortion in Romania is high, with survey estimates for 1992 showing 130 abortions per 1000 women 15-44 years of age, 71 abortions per known pregnancies, and 240 abortions per 100 live births. Thus, since the repeal of laws restricting abortion, me majority of pregnancies have ended in abortion. For this reason, it was important to determine women's attitudes toward abortion. According to data in Table 8.3.1, 72% of women surveyed believe that women always have the right to make decisions about their pregnancies, including abortion. At least two-thirds of every segment of the population believed there should be no restrictions on abortion. There were only small differences of opinion according to the variables shown. Table 8.3.2 shows that only 10% of all women believed abortion should not be permitted if the woman was not married or was having financial problems (Table 8.3.2). Fewer than 5% of all women believed mat abortion should not be permitted under various other personal circumstances, such as: the woman's health being in danger (4%); the pregnancy following rape (4%); the woman's life being in danger (3%); and the fetus having malformations (2%). With these low percentages, very little variation is seen by characteristics of the respondents. 100 101 102 The 1,373 women whose opinions are analyzed in Table 8.3.3 are the 28% of respondents enumerated in Table 8.3.1 who do not believe abortion is permissible under any circumstance. These women were asked whether they agreed abortion would be permissible in the six situations set forth in Table 8.3.3. Under four of the six circumstances—that is, the woman's life is in danger (77%), the fetus is deformed (80%), the woman's health is in danger (67%), or the pregnancy is the result of rape (64%)—the majority of these women felt an induced abortion would be permissible. In the remaining two circumstances, 40% of these women felt abortion was permissible if the couple could not afford the child and only 29% felt an abortion was permissible because a pregnant woman was unmarried. Even so, a substantial additional proportion of women, 15% and 32% respectively, said that depending on the circumstances an abortion could be permitted. Table 8.3.4 shows that in the first four personal circumstance categories, women in rural areas, women in lower educational and socio-economic categories, gypsy women, or those who attend church more frequently are slightly less likely to think that abortion should be available. In the last two circumstances (woman is unmarried, financial problems), only women with high educational attainment or those with four or more children are less likely to think abortion should be permitted. 103 104 8.4 Opinions About Modern Contraceptives Respondents were asked a series of questions in order to learn their opinions about oral contraceptives and the IUD. In Chapter VI it was noted that among women who were using traditional methods of contraception, more than 70% reported that the fear of negative health effects was the most important reason in their decision to avoid using modern methods of family planning. At the time of the survey, approximately three percent of women reported using oral contraceptives. On the whole, women were unaware of the efficacy of oral contraceptives (45%) or underestimate me pill's ability to prevent pregnancy (Table 8.4.1). Only one-fourth of respondents said that a woman who takes me pill correctly could be completely or almost sure that she would not become pregnant. In general, women in urban areas, women in the 25-39 year old age group, those in me higher education and socio-economic categories, and those who are users of contraception, especially pill users, were more aware of the efficacy of the pill. The minority of traditional method users who consider modern methods are more effective than traditional methods were also more likely to believe the pill is an effective method of contraception. Women in other groups did not generally report that the pill is not effective, but rather they did not know whether it is or not. This is especially true for rural women, less educated women, and women in the lowest socio-economic category. Overall, 43% of women said the pill is unsafe for women's health and another 38% did not know whether the pill is safe or not (Table 8.4.2). Fewer than 20% of women believed that the pill is at least somewhat safe. The percentage who felt that the pill is safe was highest for women in Bucharest and women aged 20-34 years. It was also highest among pill users, the best educated women, and those in the highest socio-economic category. As with the effectiveness of the pill, rural women, less educated women, those in the lowest socio-economic category, and non-pill users tended not to know whether the pill was safe or not. Clearly, a large proportion of women in Romania have misconceptions about oral contraceptives (see also Chapter VI). If a greater proportion of Romanian women are to be persuaded to use the pill, there is a great need for health education efforts regarding the effectiveness and safety of this method. Over half of the women (54%) agreed that me pill is easy to use and one-fourth (26%) agreed that it is not bothersome to take the pill daily (Table 8.4.3). In both cases, positive responses increase with educational attainment and is higher for Bucharest and other urban areas. Only 38% agreed that "the pill removes the fear of getting pregnant" and only one in five women (19%) knew that "the pill makes menstrual cycle more regular". Less than 20% of women thought that taking the pill "does not increase the risk of getting cancer" (19%), "does not cause infertility after long periods of time" (17%), "is not bad for blood circulation" (12%), or "does not make you nervous" (12%). 105 106 107 More accurate responses were obtained from women residing in Bucharest. The likelihood of giving a correct answer also increased as the level of educational attainment increased. Similar to the series of questions on oral contraceptives, respondents were asked two questions to learn their opinions about the IUD. As with the pill, women were generally unaware of the efficacy of the IUD (49%) or underestimated its ability to prevent pregnancy. Only 32% of respondents said that a woman whose IUD was inserted correctly could be completely or almost sure that she would not become pregnant, while almost half said they do not know (Table 8.4.4). 108 109 110 In general, women in urban areas, women in the 25-39 year old age group, those in the higher education and socio-economic categories, and those who are users of the IUD were more aware of the efficacy of the IUD. As with the pill, the minority of traditional method users who consider modern methods are more effective than traditional methods were more likely to be aware of IUD efficacy in preventing pregnancy. Women in other groups do not generally report that the IUD is not effective, but rather they did not know whether it would prevent pregnancy when inserted correctly. This is especially true for rural women, very young women, those over 40, less educated women, women in the lowest socio-economic category, as well as those never married or those in consensual union. Compared to the pill, a much lower percentage of women (20%) thought the IUD is unsafe for women's health, but a higher percentage (52%) did not know whether the IUD is safe or not (Table 8.4.5). Nonetheless, only 28% of women feel the IUD is somewhat safe, safe or very safe. The percentage believing that the IUD was safe is slightly higher among married women (31%), increases somewhat with age, and is highest among the IUD users (87%), the best educated women (52%), those living in Bucharest (42% ) those with upper socio-economic status (42%) and, interestingly, those who use condoms (46%) or rhythm (39%). As with the effectiveness of the IUD, rural, less educated women, and women in the lowest socio-economic category tended not to know whether the IUD is safe or not. As is the case with the pill, if a greater proportion of Romanian women are to be persuaded to use the IUD, there is a great need for health education efforts regarding the effectiveness and the safety of this method. 8.5 Information About Contraceptive Methods More than half of the respondents (57%) would like to have more information about contraception (Table 8.5.1). This is inversely correlated with age, with more than 75% of women under the age of 25 reporting a desire for information on this subject and only 38% and 21%, respectively, of women aged 35-39 or 40-44 years. Associated with younger age, 79% of never married women and 73 % of childless women expressed a desire for more information. Table 8.5.2 shows that most (74%) respondents feel that a doctor who is an obstetrician- gynecologist would be the most reliable person to provide information on contraception. Ten percent of respondents, particularly younger women, would rely on their mother for this information. 111 112 113 8.6 Attitudes Toward Family and Reproductive Roles Respondents were asked whether they agreed or disagreed with six statements, shown in Table 8.6.1, regarding children, sexual activity and condoms. There was considerable agreement with the first three of the statements shown. Most women agreed that it is alright for a woman to choose to not have children (78%), that it is possible for a woman to become pregnant at the time of first sexual intercourse (67%), and that a woman should be a virgin when she marries (63%). It is interesting, however, mat as many as one-third of women did not know a woman can get pregnant at first intercourse. For the first two statements, agreement was higher in more urban areas and among better educated women, while the opposite was true for me third statement on virginity at marriage. Slightly less than one-fourth of women (24%) agreed with the fourth statement that "Child care is woman's work," which along with the first statement, "It is all right for a woman to choose to not have children," indicated that most Romanian women do not feel mat women should be restricted to traditional roles. Only 13 % of respondents agreed with the fifth statement, "Use of a condom does not decrease sexual pleasure for a woman" and less than 2 percent agreed with the last statement, "It is all right to use a condom more than once." 114 Table 8.6.2 presents respondents' opinions on what a woman should do if she has an unintended pregnancy. Among those who believe that a woman always have the right to decide about her pregnancy, more than 64% considered that her decision should be to have an abortion and less than one-fourth thought that she should have the baby and keep it. Another 6% stated the baby should be given up for adoption and 7% did not know what should be done. Interestingly, there is little difference in opinions about what a woman should do if she has an unintended pregnancy by specific circumstances surrounding the pregnancy. There was some variation in opinion on this subject according to respondent characteristics (Table 8.6.3). Women in the midst of their childbearing years, between the ages of 20 and 35, were more likely to say that a woman should have an abortion. In general, urban, well-educated, higher socio-economic status women, as well as women who attend church less frequently were more likely to report that the woman in this position should have an abortion and that she not keep the baby. Women under the age of twenty were more inclined than other groups toward giving the child up for adoption, while Hungarian women were much less likely to suggest an adoption. 115 116 CHAPTER IX MATERNAL CARE 9.1 Prenatal Care One of the main objectives of the survey was to provide information about prenatal care in order to identify subgroups of women or their babies who are at higher risk of inadequate use of maternal health services. Extensive questions about the most recent pregnancy were asked of all women who had given birth in the five years prior to the survey. 117 The overall percentage of women receiving any prenatal care is 94% and varies within a narrow range according to maternal characteristics. Lower levels are recorded among women who reside in Bucharest (91%) or in rural areas (92%). The proportion of mothers who did not receive prenatal care is almost three times higher among young adults (8%) than among women aged 25- 29 (3%), the group most likely to have prenatal care. The use of prenatal care is directly correlated with educational attainment and socioeconomic status. Ten percent of mothers with primary school did not receive any prenatal care compared to only 3 % of mothers with complete secondary school or higher education. About 8% of mothers with low socioeconomic status had no prenatal care visits compared with mothers with medium or high socioeconomic status (4% and 5%, respectively). Although the vast majority of mothers at some point during their last pregnancy visited a prenatal care facility, a large proportion of them did not meet the recommendations of the MOH maternal health program. This program promotes beginning of prenatal care as soon the woman suspects she is pregnant (preferably during the first 12 weeks of pregnancy) and recommends at least 10 prenatal visits before delivery (Badea et al.,1993). Table 9.1.1 also shows that between January 1988 and June 1993 less than a quarter (23%) of mothers had 10 or more visits during their last pregnancy which resulted in a live birth. Almost 20% had only 1-3 visits, 34% 4-6 visits and 18% 7-9 visits (Figure 9.1.1). Overall, the median number of prenatal care visits was 6. The proportion of women who met the requirements of MOH/MCH program is even lower in rural areas and in the northeast part of the country (Moldavia). Is also directly correlated with age, education and socioeconomic status. The youngest mothers, those who did not complete high school and those with low socioeconomic status, have the highest level of non-compliance with the norms stipulated for periodic prenatal care visits. Table 9.1.2 shows that only slightly more than a half of mothers (57%) had complied with the norms regarding early initiation of prenatal visits, whereas 34% sought prenatal care in the second trimester and 4% in the third trimester. The median age of gestation at first prenatal care, for mothers who delivered a live born child since 1988, is three months. Since the number of visits is correlated with the trimester of pregnancy they started, women who attended prenatal care services continuously are the same women who started the visits in the early stage of pregnancy (Figure 9.1.2). For instance, mothers residing in urban areas other than Bucharest tend to start earlier (66% in the 1st trimester) and make more prenatal visits (48% with 7 or more visits), whereas residents of Bucharest are more likely to start later (43% in the 2nd or 3rd trimester) and only 40% have 7 or more visits. Women who started early and sought prenatal care most often had completed secondary school and are more likely to have medium or high socioeconomic status. 118 Prenatal care in Romania is provided mostly in dispensaries and polyclinics (Table 9.1.3). The primary care centers (dispensaries) serve a predetermined geographical area and are staffed by general practitioners, nurses and midwifes. They are attached to polyclinics where pregnant women are referred for their first Ob/Gyn assessment and for laboratory exams. If the risk assessment is favorable, most of prenatal care is provided in dispensaries and the Ob/Gyn specialist will reevaluate the pregnancy in the third trimester. If the first assessment finds specific 119 120 risk factors, most of the prenatal care will be provided in the policlinic by an Ob/Gyn and other specialists. Most of deliveries take place in hospitals and, in the rare event when home deliveries occur, postpartum mothers and their babies are referred to hospitals as soon as possible. Both prenatal care and delivery services are free of charge within the government health system but most patients will make 'informal' payments to receive better services . An increasing number of Ob/Gyns, who work in government hospitals and normally provide only inpatient care, are starting to offer prenatal care on a fee-for-service basis. Many have opened private offices outside the hospitals were they usually work and offer a combination of private care for prenatal visits and delivery care in government maternities. As shown in Table 9.1.3, for pregnancies resulting in live births since 1988, the principal source of prenatal care was the local dispensary (82% of mothers had at least one prenatal visit in a dispensary). The second most important source was the polyclinic (55%). A relatively high proportion of women sought prenatal care in governmental hospitals (24%). Only 8% received prenatal care at their homes and very few women went to private offices or clinics in the five years prior to the survey (2%). Table 9.1.4 and Figure 9.1.3 show distributions of primary providers of prenatal care by selected characteristics of mothers. Overall, 36% of women declared that most prenatal care during their last pregnancy was provided by a general practitioner and 34% said that the source for most care was an Ob/Gyn. This is somewhat surprising since a normal pregnancy requires only two Ob/Gyn visits. Only 17% of women said that their provider for most visits was a midwife and 6% saw a physician and a midwife equally. In Bucharest, the proportion of prenatal care offered by obstetricians (60%) is much higher then in the rest of the country (44% and 24%, respectively). If Bucharest is excluded, the differences in providers of prenatal care are negligible among regions. However, mothers' level of education has a strong influence on who provided the most prenatal care. Most poorly educated women saw general practitioners and midwifes for prenatal care and only 25% saw obstetricians. The proportion of prenatal care provided by obstetricians increases with the education level of mothers, reaching a maximum of 58% for the most educated women. There is a tendency for more prenatal care to be provided by OB/Gyns among women with low socioeconomic status, probably because they are more likely to have higher parity and other risk factors that require more specialized care. However, the overall percent of visits covered by physicians is similar to that among women with the higher status. Other characteristics, such as age, employment and religion have little impact on who provided most prenatal care. 121 122 123 124 In addition, prenatal care records are kept in dispensaries and polyclinics, Ministry of Health regulations concerning prenatal care require that pregnant women should carry a specific medical document (prenatal book) which is filled in by the health care personnel who observe the pregnancy. This book should include initial familial and medical history (including pregnancy history), first physical examination, laboratory tests and risk assessment, subsequent prenatal visits and counseling, common complaints, medication and brief description of eventual hospitalizations. This document is often the only source of information for health care professionals in maternities (where the majority of deliveries take place) when they admit women for delivery. However, providers of most prenatal care visits, located in dispensaries and polyclinics, do not routinely send medical information about their patients to the maternity wards, nor do they provide follow-up visits in maternities. Overall, only 34.4% of mothers stated that they carried prenatal books when they were pregnant with their last child. There is a significant difference between women residing in Bucharest, who are much more likely to carry prenatal books (69%) then women in other urban areas and rural areas (37% and 26%, respectively). Also, the likelihood of having the prenatal book is directly correlated with educational attainment and socioeconomic status. Half of well educated women had their pregnancy documentation compared with only 28% of women with low educational attainment. Additional questions were asked to assess the educational counseling offered to pregnant women and their overall level of satisfaction during prenatal care visits. Table 9.1.5 summarizes the main topics covered by health care providers during prenatal care visits. Only 60-61 % of mothers with a live birth in the last five years who sought prenatal care received information about nutrition, the adverse effects of smoking and alcohol abuse, and about the program of rest and physical activity during pregnancy. Little more than a half talked with a health care provider about the physiologic changes during pregnancy, breast-feeding and delivery. The level of satisfaction with the quality of care provided during the last pregnancy was relatively high: 66% of mothers were satisfied with the information they have received during prenatal visits and 91% acknowledged they were well treated by the health care providers. 125 9.2 Maternal Morbidity During Pregnancy More than 70% of mothers with a live birth since January 1988 did not experience any important health problems during their last pregnancy. Adverse health problems during pregnancy were considered as important if the woman was confined to bed rest for at least one week or if they had to be hospitalized. Almost 20% of women who reported a viable pregnancy had at least one important prenatal problem which required hospitalization and other 10% had to spend at least one week in bed for a prenatal problem. The median duration of hospitalization was 14 days. Questions were asked to explore what specific adverse health outcomes were experienced by women who had to be hospitalized. Most pregnant women who had been hospitalized during their 126 last pregnancy resulting in a live birth reported that they spent several days in a hospital for threatened abortion (47%) or swelling of the face or extremities (40%). About one-third said that the main reason was persistent vomiting (33%) or uterine cramping (33%). Other relatively common reasons for hospitalization were urinary infection (22%), vaginal bleeding (11%) and elevated blood pressure (11%). 9.3 Smoking During Pregnancy There is considerable evidence that women who smoke during pregnancy have smaller infants (200g lighter, on average) than women who do not smoke. In addition, they have an increased risk of poor maternal and perinatal outcomes (premature labor, placental abruption, pregnancy bleeding, premature rupture of the membranes). 127 Overall, 21 % of women were smoking at the time they found out they were pregnant. Of these, 60% continue to smoke throughout the entire duration of pregnancy (Table 9.3.1). The percentage of women who were smoking at the beginning of their last pregnancy was higher in Bucharest (28%) and other urban areas (27%), in Transylvania (26%), among women with low educational attainment (25%) and among those with high socioeconomic status (27%). However, urban women who were smoking at the beginning of pregnancy were much more likely to stop smoking during pregnancy than their rural counterparts (47% versus 25%). Also, women in Bucharest and Vallachia, women 25-34 years of age, and women with at least 9 years of formal education, were more likely to quit smoking. Women with low socioeconomic status were less likely to quit smoking (24%) compared to women with medium and high status (53% and 39%, respectively). 128 Table 9.3.2 shows that most women who did not quit smoking during pregnancy declared that they smoked, on average, less than 10 cigarettes per day (78%). Women who have smoked more than 10 cigarettes daily during their last pregnancy are more likely to reside in Bucharest (31%), to be 25-29 years of age (34%), and/or to have low educational attainment. Of women who gave up smoking during the last pregnancy that resulted in a live birth, most of them did so during the first trimester (Table 9.3.3). In Bucharest, 92% of smokers quit smoking during the first

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