Reproductive Health Survey Jamaica 1997 Final Report

Publication date: 1999

Reproductive Health Survey Jamaica 1997 Final Report National Family Planning Board February 1999 REPRODUCTIVE HEALTH SURVEY 1997 JAMAICA FINAL REPORT Carmen P. McFarlane, M.Sc. (Econ.) Jay S. Friedman, M.A. Howard I. Goldberg, Ph. D. Leo Morris, Ph.D., M.P.H. NATIONAL FAMILY PLANNING BOARD February, 1999 PRINTED BY: U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control & Prevention Atlanta, Georgia 30333 PREFACE The 1997 Reproductive Health Survey (RPS) is the sixth in a series of periodic enquiries conducted for the National Family Planning Board (NFPB) into measures of fertility, contraception and other reproductive health issues among women in the reproductive age group and young adults males. The findings are used to monitor and evaluate the effectiveness of the various interventions, which are aimed at achieving the overall goal and objectives of the national programme. It was previously called the Contraceptive Prevalence Survey (CPS) and covered a wide range of issues mainly related to family planning. With the recognition at the 1994 International Conference on Population and Development (ICPD) in Cairo that family planning is the single most important intervention in achieving reproductive health goals, it has been renamed the Reproductive Health Survey. In order to provide reproductive health services to young adults 15-24 years old, a young adult module was also included. Additional questions have been explored in the survey as they related to pap smears and breast self-examination. The findings will presented in two publications as final reports, a General Report and a Young Adult Report. We acknowledge the financial support of the United States Agency For International Development (USAID) as well as the technical support of the Division of Reproductive Health, Centers for Disease Control and Prevention (CDC) and McFarlane Consultants Ltd. in all aspects of the survey, the Statistical Institute of Jamaica (STATIN) for field work and data entry and the Population Reference Bureau for the development of a Summary Chartbook on the findings of the survey. We especially thank the Six Thousand Three Hundred and Eighty Four (6384) women and the Two Thousand Two Hundred and Seventy Nine (2279) young men who agreed to be interviewed and invited our interviewers into their homes. Beryl Chevannes (Mrs) National Family Planning Board i ACKNOWLEDGMENTS The NFPB also wishes to acknowledge the support of the following organizations and individuals who made important contributions to the development, implementation and finalization of this report. United States Agency For International Development, Kingston Dr. John Swallow, Director, Office of General Development Mrs. Grace-Ann Grey, Programme Specialist, Office of General Development Centers For Disease Control And Prevention, Atlanta Mr. Jay Friedman, Programme Analyst, Division of Reproductive Health Dr. Howard Goldberg, Deputy Chief, Division of Reproductive Health Dr. Leo Morris, Chief, Division of Reproductive Health Ms. Rebecca Amerson, Systems Analyst, Division of Reproductive Health McFarlane Consultants Mrs. Carmen McFarlane, Project Director National Family Planning Board Dr. Olivia McDonald, Medical Director Mrs. Ellen Radlein, Director Projects, Research And Statistics Mrs. Eugenia McFarquhar, Family Planning Coordinator Mrs. Janet Davis, Director, Information, Education and Communication Mrs. Jasmin Gissiawan, Regional Liaison Officer Mr. Martin Campbell, Parish Liaison Officer Mr. Neville Parkins, Regional Liaison Officer Statistical Institute Of Jamaica Mr. Vernon James, Executive Director Ms. Isbeth Bernard, Director. Division Of Surveys Mrs. Merville Anderson, Deputy Director, Division Of Census And Related Studies Mrs. Valerie Nam, Director, Division Of Census And Related Studies Ms. Day Dawn Simon, Deputy Director. Division Of Surveys Mrs. Donneth Edmondson, Systems Analyst Mr. Martin Brown, Senior Statistician, Division Of Surveys Mr. Hubert Sherrard, Senior Statistician Mrs. Sophia Bucknor, Statistician Ms. Juliet McCalla, Statistician Mrs. Phyllis Wilks, Statistician ii Ministry Of Health Dr. Eva Fuller, Principal Medical Officer, Primary Health Care Dr. Deanna Ashley, Principal Medical Officer, Secondary Health Care University Of The West Indies Dr. Affette McCaw-Binns, Department Of Community Health Population Reference Bureau, Washington Mr. Carl Haub, Demographer Ms. Julia Beamish, Health Communications Specialist iii iv CONTENTS Page No. PREFACE i ACKNOWLEDGMENTS ii TABLE OF CONTENTS iv LIST OF TABLES AND FIGURES viii EXECUTIVE SUMMARY 1 CHAPTER 1 - BACKGROUND 9 l.A Historical, Geographical, Demographic and Social Background 9 1.B Population Policies and Programmes 11 l.C Objectives of the 1997 JRHS 14 l.D Users of the Data 15 1.E Coverage of the 1997 JRHS 15 l.F Administration of the Survey 16 l.G The Sample Design 16 l.H Questionnaire Design and Development 17 1.I Recruitment and Training 18 l.J Field Work 19 l.K Response Rates 19 CHAPTER 2 - CHARACTERISTICS OF THE SURVEY POPULATION 21 2.A General 21 2.B Age Distribution of the Survey Population 21 2.C Marital and Union Status 21 2.D Educational Level 24 2.E Employment Status 24 2.F Religion 25 2.G Children Ever Born 26 2.H Socio Economic Index 26 CHAPTER 3 - FERTILITY AND FERTILITY-RELATED FACTORS 27 3.A Age At Menarche And Sexual Experience 27 3.B Breast-Feeding and Postpartum Insusceptibility 28 3.C Current Sexual Activity 29 3.D Fertility Rates 30 3.E Planning Status of Last Pregnancy 31 v Page No. CHAPTER 4 - REPRODUCTIVE HEALTH 33 4.A Maternal Health and Child Care 33 4.B Cancer Screening 37 4.C Forced Sexual Intercourse 38 CHAPTER 5 - CONTRACEPTIVE KNOWLEDGE 39 5.A Knowledge of Contraceptive Methods 39 5.B Opinions on Sexuality, Pregnancy and Attitudes to Life 40 CHAPTER 6 - CONTRACEPTIVE USAGE 43 6.A Ever Use of Contraceptives 43 6.B Initial Use Of Contraceptives 44 6.B Current Use of Contraceptives 44 6.C Source of Contraception 49 CHAPTER 7 - HORMONAL CONTRACEPTIVE USE 51 7.A Pill Use 51 7.B Injection Use 53 CHAPTER 8 - CONDOM USE 55 8.A Condom Use 55 8.B Reasons for Condom Use 56 8.C Effectiveness of Condoms: Respondent's Perception 57 CHAPTER 9 - STERILIZATION - USE AND DEMAND 59 9.A Use of Sterilization 59 9.B Satisfaction with Sterilization 59 9.C Demand for Sterilization 60 9.D Reasons for Non Sterilization 60 CHAPTER 10 - NON USE OF CONTRACEPTIVES 63 10.A Discontinuation Rates 63 10.B Reason for Not Using a Contraceptive Method 63 10.C Need for Family Planning Services 64 vi Page No. CHAPTER 11 - YOUNG ADULTS 67 11.A General 67 11.B Socio Demographic Characteristics 67 11.C Exposure to Family Life / Sex Education 67 11.D Exposure to Sexual Activity 68 11.E Contraceptive Use at First Intercourse 69 11.F Source of Condoms 69 11.G Reasons for Not Using Contraception at First Intercourse 70 REFERENCES 71 TABLES AND FIGURES APPENDIX I: SAMPLING ERROR ESTIMATES APPENDIX II: COMMENTS MADE AT NATIONAL DISSEMINATION SEMINAR APPENDIX III: QUESTIONNAIRES A. Household Questionnaire - Female (Form RHS 1 A) B. Individual Questionnaire - Female (Form RHS 2) C. Household Questionnaire - Male (Form RHS 1B) D. Individual Questionnaire - Male (Form RHS 3) vii LIST OF TABLES AND FIGURES 1.1 Household And Individual Interview Status Women Aged 15-49 And Men Aged 15-24 2.1 Age Distribution Of Women 15-49 By Five-Year Age Group, Compared With 1989, 1993 CPSs And 1987, 1992, 1996 STATIN Estimates 2.2 Union Status Of Women 15-49 Years of Age By 5-Year Age Group 2.3 Selected Socio-Demographic Characteristics Of Women 15-49 Years of Age, By 5-Year Age Group 3.1 Mean Age At First Menstrual Period Women Aged 15 to 49, By Selected Characteristics Compared With The 1993 and 1989 Contraceptive Prevalence Surveys 3.2 Percent Of Women Aged 15-49 Who Have Ever Had Sexual Relations, By Age And Church Attendance, Compared To 1993 CPS 3.3 Percent Of Young Adult Men Aged 15-24 Who Have Ever Had Sexual Relations, By Age And Church Attendance, Compared To 1993 CPS 3.4 Percent Of Women 15-49 Who Had Their First Sexual Relation And Their First Birth Before Selected Ages And Median Age At First Sexual Relation And First Birth, By Current Age Group 3.5 Percent Of Women 15-49 Who Breast-Fed Their Last Child And The Mean Duration Of That Breast-Feeding, By Selected Characteristics. Women 15-49 Who Had A Birth Within 5 Years Of Their Interview 3.6 Percent Of Women 15-49 Who Had A Birth In The 24 Months Prior To The Survey Who: 1. Are Still Breast-Feeding; 2. Are Post-Partum Amenorrheic; 3. Have Not Resumed Sexual Intercourse; 4. Are Post- Partum Insusceptible. By Number Of Months Since Last Birth. 3.7 Percent Of Women 15-49 Who Had A Birth In The 24 Months Prior To The Survey Who: 1. Are Still Breast-Feeding; 2. Are Post-Partum Amenorrheic; 3. Have Not Resumed Sexual Intercourse; 4. Are Post- Partum Insusceptible. By Selected Characteristics. 3.8 Respondents' Opinion Of Ideal Breast-Feeding Duration, By Selected Characteristics. Women Aged 15-49 3.9 Percent Of Women 15-49 Who Are Currently Sexually Active, By Current Relationship Status 3.10 Relationship With Last Sexual Partner, By Current Relationship Status Women Aged 15-24 Who Are Sexually Active. viii 3.11 Of Women 15-49 Who Are Not Currently Sexually Active, The Percentage Who Have Had Sexual Intercourse In The Past Three Months By Relationship Status. 3.12 Percent Of Young Adult Men Who Are Sexually Active, By Current Relationship Status. 3.13 Relationship With Last Sexual Partner, By Current Relationship Status Young Adult Men Aged 15-24 Who Are Sexually Active. 3.14 Age-Specific Fertility Rates And Total Fertility Rate (TFR) Jamaica, By Maternal Age, Compared With 1975 Fertility Survey, 1983 JCPS, 1989 JCPS, 1993 JCPS Fig. 1 Age-Specific Fertility Rates, Women Aged 15-44, Compared To 1993 JCPS. 3.15 Age-Specific Fertility Rates And Total Fertility Rate (TFR) Jamaica, By Maternal Age And By Area Of Residence. 3.16 Percent Of All Women 15-49 Years Of Age Who Are Childless, By Current Age Group And Selected Characteristics. Total Compared With 1989 And 1993 Contraceptive Prevalence Surveys. 3.16 Planning Status Of Current Pregnancies And Most Recent Pregnancies Resulting In A Live Birth, According To Selected Characteristics And Total Compared With 1989 And 1993 CPSs. Women 15-44 Who Had A Live Birth In The Previous 5 Years Or Who Are Currently Pregnant. Fig. 2 Planning Status Of Last Or Current Pregnancy, By Selected Characteristics. Women Aged 15-44. 3.18 Number Of Additional Children Desired By Women 15-49 Years Of Age, By Current Number Of Live Births (Percent Distribution). 3.19 Age Respondents Consider A Woman Is Responsible Enough To Have Her First Child. Women Aged 15-49, By Selected Characteristics 4.1 Source Of "Most" Of Prenatal Care For All Pregnancies Resulting In Live Births In The Previous Five Years. Women Aged 15-49 Who Had Prenatal Care, By Selected Socio demographic Characteristics. Total Compared To 1989 And 1993 Contraceptive Prevalence Surveys. 4.2 Source Of "Most" Of Prenatal Care For All Pregnancies Resulting In Live Births In The Previous Five Years. Women Aged 15-49 Who Had Prenatal Care, By Geographic Characteristics. (Percent Distribution) 4.3 Number Of Visits For Prenatal Care For All Pregnancies Resulting In Live Births In The Previous Five Years. Women Aged 15-49 Who Had Prenatal Care, By Selected Characteristics. ix 4.4 Month Of Pregnancy When Prenatal Care Began For All Pregnancies Resulting In Live Births In The Previous Five Years. Women Aged 15-49 Who Had Prenatal Care, By Selected Characteristics. (Percent Distribution) 4.5 Percent Of Pregnancies Of Women 15-49 In The Past 5 Years That Were Classified As High Risk According To Age And Parity Criteria, By Selected Characteristics 4.6 Percent Of All Pregnancies And High Risk Pregnancies Of Women 15-49 In Previous 5 Years For Which The Timing And Number Of Visits During Prenatal Care Was Inadequate According To Ministry Of Health Criteria, By Selected Characteristics 4.7 Adequacy Of Number Of Visits For Prenatal Care Of High Risk Pregnancies Resulting In Live Births In The Past 5 Years Of Women Aged 15-49 Who Had Prenatal Care According To Ministry Of Health Criteria And By Selected Characteristics (Percent Distribution) 4.8 Percent Of Normal Risk Pregnancies Of Women 15-49 In Past 5 Years For Which The Number Of Visits During Prenatal Care Was Inadequate According To Ministry Of Health Criteria, By Whether First Or Subsequent Pregnancy And By Selected Characteristics 4.9 Percent Of Ever Pregnant And Currently Pregnant Women Aged 15-49 Who Smoked Cigarettes And/Or Drank Alcohol During Their Last Or Current Pregnancy, By Selected Characteristics 4.10 Percent Of Women Told They Had High Blood Pressure During Their Most Recent Pregnancy. Women Aged 15-49 Whose Blood Pressure Was Checked During Pregnancy In The Past 5 Years, By Selected Characteristics 4.11 Percent Of Women Who Received One Or More Tetanus Injections During Pregnancies In The Past 5 Years, By Selected Characteristics 4.12 Place Of Delivery Of All Pregnancies Resulting In Live Births In The Past Five Years. Women Aged 15-49, By Selected Characteristics 4.13 Principal Person Who Assisted At Delivery Of All Pregnancies Of Respondents Which Resulted In Live Births In The Past 5 Years. Women Aged 15-49, By Selected Characteristics 4.14 Percent of Women Aged 15-49 Who Have: Ever Had A Pap Smear; And Who Had A Pap Smear In The Past 2 Years; And Who Have Had A Pap Smear In The Past Year. By Selected Characteristics x 4.15 Percent of Women Aged 15-49 Who Have: Been Taught By A Health Professional To Do A Breast Self-Examination; Who Have Ever Done A Breast Self-Examination; And Percentage Who Did A Breast Self- Examination In The Past Year And In The Past Month. By Selected Characteristics 4.16 Percentage Of Sexually Experienced Women Aged 15-49 Who Have Ever Been Forced To Have Sexual Intercourse, By Selected Characteristics. 4.17 Relationship To Last Person Who Forced Respondents To Have Sexual Intercourse. Women Aged 15-49 Who Have Ever Been Forced To Have Sexual Intercourse, By Current Union Status 5.1 Percent of Women Aged 15-49 Who Have Heard of Specific Contraceptive Methods Compared With with 1993 and 1989 Contraceptive Prevalence Surveys 5.2 Percent of Young Adult Men Aged 15-24 Who Have Heard of Specific Contraceptive Methods Compared With with 1993 Contraceptive Prevalence Survey 5.3 Percent of Women Aged 15-49 Who Have Heard of Specific Contraceptive Methods, By 5-Year Age Group 5.4 Percent of Women Aged 15-49 Who Have Heard of Specific Contraceptive Methods, By Area Of Residence 5.5 Percent of Women Aged 15-49 Who Have Heard of Specific Contraceptive Methods, By Years Of Education 5.6 Respondents' Opinion Of Ideal Interval Between Births, By Selected Characteristics. Women Aged 15-49 5.7 Percent of Women Aged 15-49 Who Agree Or Disagree With Selected Statements On Sexuality, Pregnancy And Attitudes To Life, By Years Of Education 6.1 Percent of Women 15-49 Who Have Ever Used Any Contraceptive Method, By Selected Characteristics, Compared With 1993 CPS 6.2 Percent of Women Aged 15-49 Who Have Ever Used Specific Contraceptive Methods. Compared With with 1993 and 1989 Contraceptive Prevalence Surveys 6.3 Mean Age (In Years) When Women 15-44 First Used A Contraceptive Method, By Selected Characteristics, Compared With 1993 Contraceptive Prevalence Survey xi 6.4 Number Of Living Children When Women Aged 15-44 First Used A Contraceptive Method, By Selected Characteristics Compared With 1993 Contraceptive Prevalence Survey 6.5 Percentage of All Women Aged 15-49 Currently Using Contraception By Relationship Status and Method Compared With 1993 Contraceptive Prevalence Survey 6.6 Percent of Women In Union Aged 15-49 Who Are Currently Using Any Contraceptive Method By Selected Characteristics, Compared With 1993 CPS 6.7 Percentage of Women Aged 15-49 Currently in a Union Who Are Currently Using Contraception, By Method Compared With 1983, 1989, and 1993 CPSs 6.8 Percent of Women In Union Aged 15-49 Who Are Currently Using Any Contraceptive Method, Any Modern Method Or Any Traditional Method By Selected Characteristics 6.9 Percentage of Women In Union 15-49 Currently Using Contraception By Age Group and Method, Compared With 1993 Contraceptive Prevalence Survey Fig. 3 Percentage of Women In Union Aged 15-49 Currently Using A Contraceptive Method, By Age Group 6.10 Mean Age of Women Aged 15-44 Currently in a Union By Contraceptive Method Used, Compared With 1993 CPS 6.11 Percent Of Young Adult Men Who Used Contraception With Their Last Sexual Partner. Men Aged 15-24 Who Had Sexual Relations In The Last 30 Days, By Age Group and Method Used. Compared With 1993 Contraceptive Prevalence Survey 6.12 Percentage of Women In Union 15-49 Currently Using Contraception By Health Region and Method. Total Compared With 1993 Contraceptive Prevalence Survey (Percent Distribution). 6.13 Percentage of Women In Union 15-49 Currently Using Contraception By Number Of Live Births and Method. Total Compared With 1993 Contraceptive Prevalence Survey 6.14 Percentage of Women In Union 15-49 Currently Using Contraception By Years Of Education and Method 6.15 Percentage of Women In Union 15-49 Currently Using Contraception By Frequency Of Church Attendance and Method xii 6.16 Percentage Of Contraceptive Users Who Are Concurrently Using A Secondary Contraceptive Method, By Primary And Secondary Method Used, Women In Union Aged 15-49 6.17 Source Of Most Prevalent Contraceptive Methods, By Method Currently Used And Urban Or Rural Residence. Women In Union Aged 15-49 6.18 Comparative Data From 1993 CPS On Source Of Most Prevalent Contraceptive Methods, By Method Currently Used And Urban Or Rural Residence. Women In Union Aged 15-44 Fig. 4 Source Of Contraception Of Women In Union Who Are Currently Using Most Prevalent Contraceptive Methods (Percent Distribution), Compared With 1993 And 1989 CPSs. 6.19 Source Of Most Prevalent Contraceptive Methods, By Method Currently Used. Women Not In Union Aged 15-49 6.20 Availability Of Family Planning Services At Government Clinics / Health Centres Reported By Women Aged 15-49 Who Obtain Contraception From Government Sources, By Selected Characteristics 6.21 Length Of Time To Travel To Source Of Contraception, Reported By Women Aged 15-49, By Selected Characteristics 7.1 Percentage Of Women 15-49 Who Have Ever Heard / Read A Media Family Planning Message, And Percentage Who Have Ever Heard Or Read A Media "Personal Choice" Message, By Selected Characteristics 7.2 Type Of Pill Program And Brand Of Pill Used, By Residence Women 15-49 Who Are Current Users Of The Pill (Oral Contraceptives) 7.3 Type Of Pill Program And Brand Of Pill Used, By Socio-Economic Index Women 15-49 Years Of Age Who Are Current Users Of The Pill 7.4 Respondents' Perceptions Of Effectiveness Of The Pill To Prevent Pregnancy. Women Aged 15-49 By Selected Characteristics 7.5 Respondents' Perception Of Safety Of The Pill For A Woman's Health Women 15-49 By Selected Characteristics 7.6 Respondents' Perceptions Of Safety Of Injectable Contraceptives For A Woman's Health, Women Aged 15-49 By Selected Characteristics 8.1 Of Women Aged 15-49 Who Have Ever Had Sexual Relations, The Percentage Who Have Ever Asked A Partner To Use A Condom And The Percentage Who Have Ever Had A Partner Suggest That He Wear A Condom, By Selected Characteristics xiii 8.2 The Percent Of Respondents / Partners Who Report Various Negative Reactions By Their Partners Or Themselves To Suggestions About Using Condoms, Women Aged 15-49 Who Have Ever Asked A Partner To Use A Condom Or Who Have Ever Had A Partner Suggest To Her That He Wear A Condom, By Years Of Education 8.3 The Percent Of Respondents / Partners Who Report Various Negative Reactions By Their Partners Or Themselves To Suggestions About Using Condoms, Women Aged 15-49 Who Have Ever Asked A Partner To Use A Condom Or Who Have Ever Had A Partner Suggest To Her That He Wear A Condom, By Area Of Residence 8.4 Percentage Of Women Who Used A Condom At Last Sexual Intercourse By Reported Condom Use Status And Selected Characteristics. Women Aged 15-49 Who Ever Had Sexual Relations 8.5 Reasons For Using Condoms And Frequency of Condom Use With Steady And Non-Steady Partners, Women Aged 15-49 Who Currently Use Condoms As A Primary Or Secondary Method, By Age Group 8.6 Respondents' Perceptions Of Effectivness Of Condom In Preventing Pregnancy, Women Aged 15-49 By Selected Characteristics 8.7 Respondent's Perception Of Effectivness Of Condoms In Preventing Sexually Transmitted Diseases. Women Aged 15-49 By Selected Characteristics 9.1 Characteristics Of Sterilized Women Compared With Non-Sterilized Women. Women In Union Aged 15-44, By Selected Characteristics Compared With 1993 Contraceptive Prevalence Survey 9.2 Characteristics Of Sterilized Women In Union Aged 15-44 At Time Of Sterilization. Compared With 1993 And 1989 Contraceptive Prevalence Surveys 9.3 Mean Number Of Children Ever Born To Women In Union Aged 15-49 By Age And Whether Or Not Sterilized Compared With Data From 1993 Contraceptive Prevalence Survey 9.4 Percent Of Sterilized Women Who Were Not Satisfied With The Operation, By Selected Characteristics 9.5 Percent Of Women Who Are Interested In Sterilization, By Selected Characteristics. Fecund Women Aged 15-49 Who Do Not Want Any More Children, Compared With 1993 Contraceptive Prevalence Survey 9.6 Reasons Why Women Aged 15-49 Who Do Not Want More Children Are Not Interested In Being Sterilized, By Years Of Education xiv 9.7 Reasons Why Women Aged 15-49 Who Do Not Want Any More Children And Who Are Interested In Being Sterilized Are Not Yet Sterilized, By Years Of Education 9.8 Percent Of Women Who Would Be Interested In Sterilization After Having All The Children They Want, By Selected Characteristics. Fecund Women Aged 15-49 Who Want Or Might Want More Children. 9.9 Reasons Why Women Aged 15-49 Who Want Or Might Want More Children Are Not Interested In Being Sterilized When They Have All The Children They Want, By Age Group 10.1 Contraceptive Discontinuation Rates: Percent Of Women Aged 15-49 No Longer Using The Pill, Injectables And Condoms After 12, 24 And 36 Months, By Health Region 10.2 Contraceptive Failure Rates: Percent Of Women Aged 15-49 Who Reportedly Became Pregnant While Using The Pill, Injectables And Condoms After 12, 24 And 36 Months, By Health Region 10.3 Reasons for Not Currently Using a Contraceptive Method. Women Aged 15-49, Compared With Data From 1993 CPS 10.4 Reasons for Not Currently Using a Contraceptive Method, By Relationship Status. Women 15-49 Not Currently Using a Method 10.5 Reasons for Not Currently Using a Contraceptive Method, By Selected Last Used Contraceptive Methods, Women 15-49 Not Currently Using a Method 10.6 Percent Of Users Of Selected Contraceptive Methods Who Would Prefer To Use A Different Contraceptive Method, By Current And Preferred Method. Women Aged 15-49 10.7 Percent of Women Aged 15 to 44 Estimated To Be In Need of Family Planning Services, By Selected Socio-Economic Characteristics And Compared To 1993 CPS 10.8 Percent of Women Aged 15 to 44 Estimated To Be In Need of Family Planning Services, By Selected Geographic Characteristics 11.1 Age Distribution, Young Adult Women And Men Aged 15-24 Compared With 1993 Jamaica Contraceptive Prevalence Survey And 1987 Young Adult Reproductive Health Survey 11.2 Employment Status By Age Group And Sex. Young Adult Women And Men Aged 15-24 11.3 Relationship Status By Current Age And Sex Young Adult Women And Men Aged 15-24 xv 11.4 Percentage Of Young Adult Women And Men Aged 15-24 Years Who Took A Course In Family Life Or Sex Education By Where Course Was Taken And Age Group Compared With 1993 Jamaica Contraceptive Prevalence Survey 11.5 Proportion Of Young Adult Women And Men Aged 15-24 Years Whose School-Based Class Or Course On Family Life Or Sex Education Included Various Topics Compared With 1993 Jamaica Contraceptive Prevalence Survey 11.6 Proportion Of All Young Adult Men And Women Aged 15-24 Years Who Know Where To Go For: 1. Information On Sex Or Contraceptives; 2. Treatment For A Sexually Transmitted Disease. By Age Group, Socio- Economic Status And Whether Had Family Life Or Sex Education Course 11.7 Percent Of Young Adult Women And Men Aged 15-24 Who Have Ever Had Sexual Relations, By Age Group. Compared With 1993 Jamaica Contraceptive Prevalence Survey 11.8 Mean Age At First Intercourse, By Selected Characteristics. Young Adult Women And Men Aged 15-24 Who Are Sexually Experienced. Compared With 1993 Jamaica Contraceptive Prevalence Survey 11.9 Relationship To First Sexual Partner By Age At First Intercourse Young Adult Women And Men Aged 15-24 Years Who Are Sexually Experienced 11.10 Percentage Of Sexually Experienced Young Adults Aged 15-24 Years Who Used Contraception At First Intercourse, By Selected Characteristics And Age At First Intercourse, Compared With 1993 CPS 11.11 Source Of Condoms Used At First Intercourse, Compared With 1993 CPS. Young Adult Women And Men Aged 15-24 Years Who Used Condoms At First Intercourse 11.12 Reasons For Not Using Contraception At First Intercourse Compared With 1993 CPS. Young Adult Women Aged 15-24 Years Who Did Not Use Contraception At First Intercourse. xvi EXECUTIVE SUMMARY INTRODUCTION The Executive Summary summarizes the findings of the Reproductive Health Survey (JRHS) carried out in Jamaica in 1997 among women aged 15-49 and young adult men aged 15-24. A similar contraceptive prevalence survey was carried out in 1993 among women aged 15-44 and men aged 15-54. The 1997 JRHS, therefore, not only provided data on the current situation in Jamaica regarding reproductive health and contraceptive practices, but also permitted an evaluation of changes since 1993. The 1997 JRHS utilized an updated sampling frame which has been adopted for the Continuous Social and Demographic Surveys conducted by the Statistical Institute Of Jamaica (STATIN). Of 15,140 households selected in the survey of women, there were 6,641 eligible female respondents identified (43.9%), of whom 6,384 (96.1%) were successfully interviewed. Of 13,919 households selected in the survey of young adult men, there were 2,470 eligible male respondents identified (17.7%), of whom 2,279 (92.3%) were successfully interviewed. SURVEY RESULTS Fertility Overall, fertility in Jamaica has been stable in recent years, following a rapid decline. From a Total Fertility Rate (TFR) of 4.5 in 1975, the rate fell to 2.8 in 1997. However, the rate has been almost unchanged since 1989. In general, age-specific fertility rates (ASFR) have fallen in older age groups, while the ASFR has increased among 15-19 year olds in recent years. The failure of fertility to decline more since 1989 seems surprising, given the increase in reported contraceptive use by women in union from 55% in 1989 to 62% in 1993 to 66% in 1997. However, when fertility is plotted against contraceptive prevalence, the TFR falls almost exactly where it is expected (i.e., a population with the contraceptive use level reported for Jamaica would be expected to have a TFR of about 2.8). Since the TFR according to the 1989 survey was lower than expected, it is possible that the apparent failure of fertility to decline in recent years is in reality a result of an underestimate of the 1989 TFR. Planning Status Of The Last Pregnancy A pregnancy is defined as "planned" if the woman wanted to become pregnant at the time she became pregnant. A pregnancy is "mistimed" if she wanted to become pregnant at a later date and is "unwanted" if she did not want to have any more children. "Unintended" or unplanned pregnancies combine these latter two categories. The distribution of respondents by planning status of last pregnancy within the past five years for women aged 15-49 showed that the proportion of planned pregnancies has been steadily increasing since 1989. In 1997, overall, 34 percent of pregnancies were reported by 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 1 respondents to have been planned; the majority were unintended including 43 percent mistimed and 18 percent unwanted. These percentages are an improvement from 1993, when 29 percent of pregnancies were reported were planned, 49 percent to be mistimed and 19 percent were unwanted. The proportion of unwanted pregnancies increased with age and by number of live births. Conversely, mistimed pregnancies were concentrated among younger women and women with fewer live births, when women are more likely to have spacing failures. As might be expected, the proportion of planned pregnancies was higher and the proportion of mistimed pregnancies lower in the more stable unions. The percentage of planned pregnancies rose with an increase in socio economic status and education. The percentage of unwanted pregnancies increased as age and the number of living children rose. Given the relatively high level of contraceptive use by women in union in Jamaica, the percentage of unintended pregnancies is high. Two factors may be contributing to this: the less than optimum use of temporary methods resulting in contraceptive failure; and high levels of unprotected sexual activity by women who are not in union. Prenatal Care and Reproductive Health Women received prenatal care for almost all pregnancies resulting in a live birth in the 5 years previous to the survey. The source of more that three-fourths of all prenatal care was government clinics, with a further 17 percent from private doctors. For most pregnancies, women had 6 or more visits for prenatal care and for more than half of pregnancies women began their prenatal care by the fourth month of pregnancy. According to Ministry of Health criteria for the timing and number of prenatal visits, 35 percent of pregnancies had inadequate prenatal care. Twenty-one percent of pregnancies in the five years previous to the survey were classified as high risk according to Ministry of Health criteria; 66 percent of these women received inadequate prenatal care. More than 80 percent of deliveries occurred in hospitals. Ten percent of deliveries were at home, mostly in rural areas. The principal person in attendance for almost three-fourths of deliveries was a trained nurse of midwife. Doctors were the principal person in attendance to a much greater extent in the Kingston Metropolitan Area than elsewhere. Half of Jamaican women had a Pap Smear at least once in their lifetime, but only 15 percent had one in the past year. Similarly, while 55 percent of women had ever done a breast self- examination, only 28 percent did so on a monthly basis. Knowledge Of Contraception Knowledge of contraceptives refers to whether a respondent has heard of a contraceptive method, not necessarily that she has enough knowledge of the method to be able to use it correctly. Virtually all women had heard of the condom, pill, injectables and female sterilization, and 84 percent knew of the IUD. More than three-fourths of women heard of the 2 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY withdrawal method. The diaphragm, vaginal methods, natural methods and Norplant, which are little used in Jamaica, were much less well known. While the informed choice of a contraceptive method must be left to the couple, lack of knowledge of some of the more effective methods, particularly vasectomy and the implant, reduces the choice and potential use of some available long-term methods. The percentages of women having heard of all methods was virtually unchanged from 1993 to 1997. Among young adult men, the best known methods were, as in the case of women, condoms, the pill, injectables, female sterilization and withdrawal. However, aside from condoms and the pill, all methods were less well known among men than among women. Contraceptive Use Contraceptive prevalence presented in this section applies to the use of contraceptive methods as a primary method, the measure which was used in earlier surveys. There was an increase in the percentage of women in union using contraception from 62 percent to 66 percent during the four-year period from 1993 to 1997. Most of this increase in primary method use is accounted for by an increase in the use of injectables, from 6 percent of women in union in 1993 to 11 percent 1997, undoubtedly reflecting recent campaigns to increase injectable use. The level of use of other methods by women remained essentially unchanged since 1993. Young adult men aged 15-24 who had sexual relations in the last 30 days were asked to report whether they had used a contraceptive method with their last sexual partner. Eighty percent said they had, of whom three-fourths reported that the method used was the condom. This constituted an increase from 68 percent of young men in 1993. The increase was due to an increase in condom and injectable use, as the use of other methods by young men remained unchanged from 1993. Oral contraceptives (21 percent) were the most prevalent method reported by women in union, followed by the condom (17 percent), female sterilization (12 percent) and injectables (11 percent). These were the same four leading methods reported in 1993. Young men reported the condom (61 percent) as the most prevalent method at last intercourse, followed by oral contraceptives (12 percent), sterilization (8 percent) and injectables (4 percent). In general, as age and the number of live births increased, women tended to use more effective methods. While condom use predominated among women 19 years and under, since almost half of women in this age group using any method used the condom, the pill became the leading method used between 20 and 34 years of age. After age 35, the pill was, in turn, eclipsed by female sterilization as the major method. By age 40 the majority of women using any method were using surgical contraception. The pattern was similar as the number of live births increases. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 3 Reasons For And Frequency Of Condom Use Twenty-three percent of women indicated that they used condoms only to prevent pregnancy, 25 percent only to prevent a sexually transmitted disease, while 50 percent used condoms for both reasons. This contrasts with the 1993 survey when 29 percent reported that they used condoms to prevent pregnancy, 6 percent to prevent sexually transmitted diseases and 65 percent to prevent both. Approximately one-half of condom-using respondents reported that with a steady partner they always used a condom. A further one-third reported using it most of the time, while 17 percent reported using it some of the time. It is important to note, however, that in reporting condom use with a non-steady partner more than three-fourths of female condom users said that they did not have a non-steady partner. Of those few who acknowledged having a non-steady partner, there was roughly an even split between those who always used and those who never used a condom. The use of condoms depends on correct and consistent use. For female users of condoms, even if they are using another method, consistent condom use should be encouraged as a secondary method as a disease prevention measure. Dual Method Use Among women in union, use of a secondary method together with their primary method has increased from 5 percent of users in 1993 to 12 percent of users in 1997 who were also using a secondary method. Condoms accounted for almost all secondary method use (11 percent of users of a primary method). Less than one percent of all users were using a secondary method other than condoms. Broken down by primary method used, almost one-quarter of pill users also used condoms as a secondary method, followed by 14 percent of injection users. Six percent of sterilized women also used condoms, as did 9 percent of IUD users. While data on primary method use show no increase in condom use since 1993, data on secondary use show that, in fact, there was an increase. In assessing condom use, supply managers and logisticians must therefore take note of users for whom the condom is a secondary method. Pill Use There are three marketing strategies for the pill in Jamaica. The first is the public sector programme in government health facilities, which distributes Lo-Femenal and Ovral brands. The second is the Social Marketing Programme, known as the "Personal Choice Programme", which sells Perle and Minigynon brands. The commercial sector sells Nordette, Tri-Regol, Gynera and others. Female pill users were asked the brand they use, which were then classified by type of programme. The Personal Choice programme was the largest source of oral contraceptives. Broken down by residence, the commercial sector was the most heavily patronized in the Kingston Metropolitan Area, while other urban residents favoured the Personal Choice 4 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY Programme and rural residents used the public sector programme to the greatest extent. Two of the three brands sold in the commercial sector, Nordette and Tri-Regal as well as the "other" group, had their highest percentage of use in the Kingston Metropolitan Area and their lowest in rural areas. Source Of Contraception The sources of the four major methods for women varied according to the method used. In 1997, women largely obtained their pills and condoms in pharmacies and to a lesser extent in government health centres, with urban users patronizing pharmacies to a greater extent than rural users. The most significant additional source was shops and supermarkets for condoms, from which 16 percent purchased their condoms. Since they require a medical intervention, almost all injections and female sterilizations were obtained from government health centres and government hospitals in 1993 and 1997. The major difference in the sources of contraception since 1993 was that more use was made of pharmacies for pills and, especially, condoms, while use of government health centres fell; this signaled a continued shift to the private sector as a source for these methods. Almost one-third of women who had to travel to their source of contraception were able to the site in less than 15 minutes and a further third could do so in less than 30 minutes. A greater percentage of women in rural areas had to travel longer than 30 minutes to reach their contraceptive source, as presumably their sources were located at some distance in a village or town. Conversely, fewer women in higher socio economic groups had to travel more than 30 minutes to their source of contraception, no doubt because they had greater access to private means of transport. Sterilization: Use And Demand Compared with non-sterilized women, sterilized women tended to be older than the non-sterilized, to have had over two children more on average, to have been in a more stable relationship, to have been less educated and to have attended church more frequently. In Jamaica sterilized women tend to be self-selected for their higher parity; that is more than half of all sterilized women had four or more children, and half of all pregnancies among women who had four or more live births were unwanted. These data did not change from 1993. In 1997, 23 percent of women who were capable of getting pregnant and who did not want any more children stated that they were interested in having the operation, a decrease from the 35 percent of 1993. Non-sterilized women who did not want more children, but were not interested in sterilization, were asked the reason. Twenty-six percent indicated that they were afraid of the operation and another 15 percent of women identified fear of the method and possible side effects. Certainly women in this latter group could be the target of educational efforts to inform them of the benefits and safety of female sterilization. Among those women who were interested in sterilization, but not yet sterilized, one out of four women cited lack of information or fear of the operation. IEC messages could be aimed at those 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 5 women. Of those women who indicated that they still wanted children, 25 percent would be interested in sterilization after they had all the children they wanted. As the number of respondents' live births increased, the percentage interested in sterilization increased up to three births and then fell off. For those women who indicated that they would not be interested in sterilization even after they had all the children they want, the most frequent reasons were: "fear of the operation", followed by "may want to have more children in the future". Also, "fear of method and side effects" was cited by 16 percent of these respondents. Presumably, education efforts could convince a proportion of this large group of women of the safety of tubal ligation. Discontinuation And Failure Rates Of Contraceptives Since the tendency is to switch from short term to long term methods, such as injectables and tubal ligation, discontinuation rates or the percentage of users of the pill, injectables and condoms who discontinued after selected periods of time were calculated. After 12 months, the percentage of users who have discontinued using the condom was 42 percent compared with 32 percent for the pill and 31 percent for injectables; after 24 months, the comparative rates were 59, 48 and 50 percent, respectively, while after 36 months, they were 67, 61 and 58 percent, respectively. Contraceptive failure rates were based on respondent's reports of having become pregnant while using a contraceptive, regardless of whether the pregnancy resulted from a failure of the method or improper use of the method. Twelve-month failure rates for Jamaica as a whole were found to be about 4% for pills, 0.3% for injectables, and 5% for condoms, which are not out of the ranges typically found for each of these methods. Young Adults Although a separate report on data pertaining to young adults will be published, a summary is presented in this report. The percentage of young adults who have taken a course in family life or sex education increased since 1993 from 80 to 86 percent for women and from 68 to 76 percent for men. School-based courses were the most common for women and men. Eighty-eight percent of young women and 83 percent of young men indicated that they knew where to go for information on sex or contraception. Both women and men in the youngest age group were least likely to know where to go, while those who took a family life or sex education course or were in the higher socio economic category were more likely to know than others. The pattern was similar for those who knew where to go for the treatment of sexually transmitted diseases, but overall knowledge was higher. The majority of women and men aged 15-24 reported (70 and 85 percent, respectively) that they had sexual intercourse. As expected, the proportion increased with age; 38 percent of young women and 64 percent of young men were sexually experienced by age 18, and by age 25 nearly 6 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY all women and men were sexually experienced. Women reported a decline in sexual experience since 1993, although this decline was barely significant statistically (p=0.06) among 15-19 year olds. Virtually all young women and men reported that their first sexual experience occurred outside of a consensual union or legal marriage. Fifty-six percent of young women reported use of contraception at first intercourse and this proportion was significantly higher than the 43 percent who used contraception at first intercourse in 1993. Those who were older at first intercourse were generally more likely to have used contraception. Thirty-one percent of young men reported in 1997 that they used contraceptives at their first sexual intercourse. This is 9 percentage points (44 percent) more than was reported in 1993, which was in itself half again as great as the proportion of young men who so reported in 1987. Nonetheless, 31 percent was well below the level reported by women, in part attributable to the younger age of men at first intercourse, as the likelihood of contraceptive use generally increased with age at first intercourse. Almost all contraceptives used at first intercourse were condoms. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 7 Chapter 1 -Background CHAPTER 1 BACKGROUND 1.A HISTORICAL, GEOGRAPHICAL, DEMOGRAPHIC, AND SOCIAL BACKGROUND Jamaica, located in the northwestern section of the Caribbean archipelago, is one of a group of four islands that comprise the Greater Antilles. It is situated at latitude 18° north and longitude 77° west and is approximately 90 miles south of Cuba and 100 miles west of Haiti. The inhabitants speak English and share common cultural links with the other English-speaking territories of the region. At the regional level, it is a member of CARICOM, the Caribbean Community; at the international level, it is one of the group of countries that form the Latin American and Caribbean Region (ECLAC). The island is 146 miles long; the width varies from 22 to 51 miles, with a total area of 4,411 square miles (11,244 square kilometers). It is divided into three counties, Cornwall in the west, Middlesex in the central area and Surrey in the east. There are fourteen parishes: Kingston, St. Andrew, St. Thomas and Portland in the county of Surrey; St. Mary, St. Ann, Manchester, Clarendon and St. Catherine in the county of Middlesex; and Trelawny, St. James, Hanover, Westmorland and St. Elizabeth in the county of Cornwall. Other administrative areas have been defined and used for many purposes, the most important being the breakdown into constituencies, the political divisions of the country. The significant administrative division for this study is the breakdown into four health regions, which have varied over time, but currently comprise the following parishes: ƒ Region 1 Kingston, St. Andrew, St. Thomas, St. Catherine ƒ Region 2 Portland, St. Mary, St. Ann ƒ Region 3 Trelawny, St. James, Hanover, Westmorland ƒ Region 4 St. Elizabeth, Manchester, Clarendon The population of Jamaica at the end of 1996 was 2,527,600 and the annual growth rate was 1.0 percent. The crude birth rate (per 1,000 mean population) was then 22.8 with an 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 9 Chapter 1 - Background equivalent crude death rate of 5.9, resulting in a rate of natural increase of 16.9 per 1,000 mean population. This compares with intercensal crude birth and death rates of 39.6 and 32.2, respectively, in 1861, which represents a rate of natural increase of 7.4 per 1,000 population or 0.7 percent. Thus, both birth and death rates declined substantially. Death rates fell faster than birth rates until the early 1970s; since then, birth rates, which are still significantly higher, have shown faster rates of decline. (Statistical Institute Of Jamaica, 1996) Another important factor is the distinction between urban and rural areas. It is generally recognized that residential location can have an impact on the quality of life and accordingly can exert a strong influence on attitudes and behaviours. Thus, the sample design for the 1997 Jamaica Reproductive Health Survey (JRHS) allowed for differentiation of results according to urban and rural residence. The breakdown into urban and rural is not based on predetermined characteristics inherent in the derived data; instead, areas are defined as urban by the census if they satisfy pre determined basic criteria of urban living. In the population censuses, two types of urban areas were identified, major urban and other urban. For the purposes of the 1997 JRHS, the only major urban area was the Kingston Metropolitan Area; all other urban areas were considered "other urban", and all other areas were classified as "rural". Table A indicates the total population of Jamaica in different urban areas for the census years 1960 and 1991. The five urban centres covered include the township of Portmore, which was developed during the 1970s as a dormitory for the Kingston Metropolitan Area. It was rural before then and has been considered urban only since the 1982 census. In general, growth in the urban areas has increased, from some 27 percent of the population of Jamaica in 1960 to 41 percent in 1991. The percent in the Kingston Metropolitan Area varied 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 10 Chapter 1 - Background over the three decades but was slightly higher at the end than at the beginning; in all other areas there were marked increases. (Statistical Institute Of Jamaica, 1997) Age distribution is important to any study of fertility, contraceptive behaviour and reproductive health. Of particular significance is the proportion of women of childbearing age. The proportion of young adults, both male and female, in the population is also important. In general, the population under 15 years of age has been identified as the infant and child population and the population between the ages of 15 and 49 years (in some instances 44 years is used as the cut- off age) is the reproductive age population. Demographic enquiries and, in particular, contraceptive prevalence and reproductive health surveys have focused on breakdowns of the population into these broad age groupings. Table B presents breakdowns of the population in 1992 and 1996 by age and sex. Little change has occurred between the two periods for either sex, although young adults 15-24 years of age represented a slightly lower proportion of the total population in 1996 than in 1992. (Statistical Institute Of Jamaica, 1997) 1.B POPULATION POLICIES AND PROGRAMMES It is generally recognized that adoption and promotion of positive population policies by a country can have a significant social and economic impact on its people and can improve their quality of life. The United Nations defines population policy as "Measures and programmes designed to contribute to the achievement of social, economic and other collective goals through affecting critical demographic variables - mainly size and growth in the population, its 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 11 Chapter 1 - Background geographical distribution (local and abroad), and its demographic characteristics. The current population policy in Jamaica has been articulated in a document entitled "A Statement of National Population Policy", published in 1983 and revised in 1998. The definition of a population policy as set out in the document is "A coherent set of national priorities in terms of optimal size and growth of population, consistent with sustained social and economic growth and development". Nine basic goals have been identified, three of which are quantitative and six qualitative. These are: population growth and size, fertility, mortality, external migration, internal migration and urbanization, gender, children, the aged and the environment. Those that are relevant to this study are: Quantitative Goals ‡ Population Growth and Size: To ensure that the population does not exceed the number of persons that can be supported by the nation at satisfactory standards of living. In order to achieve this, the population should have a maximum growth rate of 0.8 per cent per annum over the next three decades. On this basis, the population would not exceed 2.7 million by the year 2000, or 3.0 million by the year 2020. This growth is in keeping with a downward trend to the ultimate goal of zero population growth. It is important to ensure that certain levels of fertility, mortality and external migration are achieved and maintained. ‡ Fertility: It is intended that the average number of children per woman, which has declined from almost six (6) in the late 1960s to 2.9 by 1989, should further decline to approximately two (2) children per woman by the year 2000 or shortly thereafter and be maintained at that level. In order to realize the goal of replacement level fertility, the Contraceptive Prevalence Rate (CPR) which was estimated at approximately 55 per cent in 1989 should reach a level of about 68 per cent by the year 2000. ‡ Mortality: To promote continued improvement in the average length of life. A specific goal is to increase average life expectancy at birth from its present estimated level of approximately 70 - 72 years to over 75 years by the year 2020. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 12 Chapter 1 - Background Qualitative Goals Š External Migration: To introduce and promote measures which will influence the flow of migration in order to: i. reduce unemployment; ii. ensure the availability of skilled manpower; iii. increase the return flow of skills and resources to meet the development needs of the country; and iv. reduce the social cost of family separation due to emigration. Š Internal Migration and Urbanization: To a balance between spatial distribution of the population and that of development, that is, investment programmes and projects. It is necessary to ensure that the spread of population and resources is such as to minimize the adverse effects on the environment. Š Gender: To promote an adequate quality of life for both sexes; a primary concern is equity between the two in social, cultural and economic matters including family life (particularly reproductive behaviour), legal status, educational opportunities, employment and income levels. Equal access to decision making processes is considered an essential element of this goal. Š Children: To ensure the provision of opportunities and conditions to enable all children to fulfil their potential and enhance their total development as individuals and responsible citizens . Specific measures to achieve this include the strengthening of Family Life Education in schools and in the wider community. The primary aim of Jamaica's population policy, which is an integral component of the Government's overall social and economic policy, may accordingly be stated as effecting greater improvement in the social and economic conditions of the people. Attainment of the goals is implicit in the specific target articulated in the Policy, whereby an objective is a population of 2.7 million or fewer by the year 2000. This will be achieved through reduction of the average family size of almost six children per family as of the late 1960s, to two per family by the late 1990s, thereby realizing the goal of replacement levels of fertility. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 13 Chapter 1 - Background To achieve this desired family size, Government's strategy is to promote a preference for smaller families through improvements in social and economic conditions. However, limitations of family size is considered to be complementary to the basic health objectives set out in the policy, a main feature of which is to ensure the highest standards of reproductive health in the population. Reproductive health as defined and ratified at the 1994 United Nations International Conference on Population and Development (ICPD) is stated thus: Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the rights of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. Promotion of health will be in line with the objective of the World Health Organization of "health for all by the year 2000", with the responsible ministry working for "improvement in its network of health facilities while creating the optimum conditions for the private sector and for voluntary organizations to complement the activities of the public system". The responsible ministry would also continue to devote attention to maternal and child care, to the delivery of health care to the neediest strata of the population and to persons living in remote areas. The emphasis on reproductive health will see the development of a comprehensive, client-centered view of reproductive health and its promotion. This will result in the expansion of those services which provide the widest reproductive health benefits for the population. Supplementary to the implementation programme would be the promotion of health education in relation to curative strategies and prevention. This is particularly significant in the context of the growing incidence of sexually transmitted diseases, especially AIDS. In achieving the health objectives, a important goal is to increase the current average life expectancy at birth of approximately 70 years to about 73 years by the year 2000. This should be achieved by continuing reductions in fertility rates and the maintenance of acceptably low levels of mortality. 1.C OBJECTIVES OF THE 1997 JRHS The main objective of the survey programme is to obtain a wide range of information about the 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 14 Chapter 1 - Background reproductive health of women and young adult men in Jamaica. The survey aims to assess health conditions covering maternal-child health and behavioural risk factors as well as considerations relating to contraception. It examines the knowledge and practices of women, young men, and their partners as they determine levels of fertility, spacing of births and provision of services related to reproductive health. These insights will prove invaluable for projecting population size and for formulating policy relating to reproductive health and family planning. In addition to the development of policies directly concerned with population growth, a further objective is to provide information that could contribute to an effective family life education programme within and outside the formal education system, which aims at improving knowledge and practices relating to the conception and care of children. 1.D USERS OF THE DATA Major users of the data will be the National Family Planning Board, the Ministry of Health, the Jamaica Family Planning Association, the Planning Institute of Jamaica, and the Population Policy Coordination Committee as well as local and international agencies. The survey should provide these users as well as other decision makers with data that will assist in the promotion of family planning and reproductive health programmes in Jamaica. 1.E COVERAGE OF THE 1997 JRHS The survey was of women aged 15-49 years and young men aged 15-24 years. Coverage of women was the same as that of the 1983 and 1989 Jamaica Contraceptive Prevalence Surveys, whereas the 1993 survey covered women aged 15-44 years. (Powell, 1984; McFarlane and Warren, 1989) Conversely, the 1993 survey covered men aged 15-54 years, which provided information used to develop male responsibility programmes for preventing unintended pregnancies. (McFarlane et. al., 1994) The 1993 coverage of men was not repeated in this survey, as preference was given to enlarging the sample of women so as to provide information at the parish level. Thus, the 1997 JRHS was designed to be the most comprehensive of the enquiries undertaken since 1983 by providing detailed information on women in their most active reproductive years (15-49) and on young adult males in the 15 to 24-year-old group. The 1997 JRHS covered a wide cross section of topics, including birth history, contraceptive knowledge and usage, attitudes towards reproduction, and behavioural risks. Background characteristics relating to the demographic and socio economic status of the population 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 15 Chapter 1 - Background surveyed were also included. These comprised age structure, educational attainment, socio economic and employment status, religious affiliation and union status. Results are shown by health regions and by urban and rural areas of residence as well as by demographic and socio economic characteristics. These variables have been selected as being important to the assessment of current programmes and to provide guidelines to areas that might benefit from special or intensified programme efforts. Some data was also produced at the parish level to inform parish administrators of the successes or weaknesses of their programmes. Data on current fertility and levels of unintended fertility was provided as well as information on general attitudes of women and men towards desired family size and contraception, birth spacing, breast-feeding and contraceptive use. 1.F ADMINISTRATION OF THE SURVEY The 1997 Jamaica Reproductive Health Survey continued the series of surveys sponsored by the National Family Planning Board and by the United States Agency for International Development (USAID). McFarlane Consultants provided the services of Survey Director; the sample design and selection, field work, coding and editing and data entry were carried out by the Statistical Institute of Jamaica (STATIN); and data tabulations were done by the Behavioural Epidemiology and Demographic Research Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, which also provided technical consultation in all aspects of the survey. 1.G THE SAMPLE DESIGN The 1997 JRHS utilized the design adopted for the Continuous Social and Demographic Surveys conducted by the Statistical Institute of Jamaica. This design was based on a two-stage stratified sample in which the first stage is a selection of geographic areas and the second stage is a selection of dwellings. For the selection of the first stage units, the country was divided into enumeration districts (EDs), which were grouped into sampling regions consisting of a predetermined number of strata, approximately equal in size (where size is measured by the number of dwellings in each sampling region). Two EDs within each sampling region, selected with probability proportionate to size (determined by the number of dwellings), made up the sample at the first stage. At the second stage, a second predetermined number of dwellings were selected systematically from lists of dwellings arranged on a circular basis in each of the EDs designated in the first stage of selection. The third stage in this survey consisted of the random selection of one eligible male aged 15-24 or female aged 15-49 from the selected dwellings. In the 1997 JRHS, the female sample was selected at the parish level and the male sample was, as in 1993, selected at the health region level. In the general sample design used by STATIN, the first 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 16 Chapter 1 - Background stage sample was selected by using identical sampling fractions in each parish. The second stage selection of separate male and female households was made in the field. This facilitated enumeration of eligible respondents wherever possible at the first visit. The small populations of Hanover and Trelawny parishes necessitated oversampling the households in order to obtain a large enough sample to obtain meaningful estimates at the parish level. Based on these selections, and taking into consideration expected non-response rates, it was anticipated that a total of approximately 15,046 households would be needed in the female survey and 14,620 households in the male survey. The following estimates were those used for the two survey designs: Table C Estimates of Expected Households Based On Desired Number Of Individual Questionnaires Female Male Category Survey Survey Desired number of completed questionnaires 6,500 2,500 Expected non-response rate 10.0% 10.0% Proportion of households with eligible respondents 48.0% 19.0% Total no. of households expected in the sample 15,046 14,620 (6,500 ÷ .90 ÷.48) (2,200 ÷.90 ÷. 19) 1.H QUESTIONNAIRE DESIGN AND DEVELOPMENT Four separate survey instruments were developed for use in the 1997 Reproductive Health Survey; one household questionnaire and one individual questionnaire for both male and female surveys. The Household Questionnaires - Forms RHS 1A and 1B, were used mainly to record information on gender and age to identify eligible members of the household from which the third stage sample was selected. One male aged 15-24 and one female aged 15-49 were then selected by using a random number chart. The Individual Questionnaires were developed for recording the information collected from women and young adult men selected for interviewing. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 17 Chapter 1 - Background The female Individual Questionnaire (Form RHS 2) was divided into the following nine sections: Š Section I Respondent's Background Š Section II Relationship Status and Partnership History Š Section III Fertility and Maternal Morbidity Š Section IV Cancer Screening Š Section V Contraceptive Knowledge and Usage Š Section VI Attitudes towards Contraception, Childbearing and Current Sexual Activity Š Section VII Family Life and Sex Education Š Section VIII Early Sexual Experience and Child Rearing Š Section IX General Attitudes and Opinions The eight sections in the male Individual Questionnaire (Form RHS 3) are as follows: Š Section I Respondent's Background Š Section II Relationship Status and Partnership History Š Section III Family Life and Sex Education Š Section IV Reproductive History Š Section V Contraceptive Knowledge and First Sexual Experience Š Section VI Current Sexual Activity and Contraceptive Use Š Section VII Attitudes towards Childbearing and Contraception Š Section VIII General Attitudes and Opinions The individual questionnaires were designed to provide comparisons with earlier surveys including the 1975/76 Jamaica Fertility Survey (Department of Statistics, 1979); the 1983, 1989 and 1993 Contraceptive Prevalence Surveys; and the 1987 Young Adult Reproductive Health Survey (Powell and Jackson, 1988). To design the questionnaire, consultations were held between the Division of Reproductive Health, Centers for Disease Control and Prevention (CDC), whose core questionnaires for family planning, maternal-child health and young adult reproductive health surveys provided guidelines; the National Family Planning Board; the Ministry of Health, United States Agency for International Development, the Survey Director; and the Statistical Institute of Jamaica. 1.I RECRUITMENT AND TRAINING The Statistical Institute of Jamaica was responsible for the field work, editing the questionnaires and data entry. Accordingly, it was in charge of recruiting field staff, editors and data entry staff. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 18 Chapter 1 - Background Because of the sensitive nature of the questions in the survey, only female interviewers were used in the female survey; in the male survey, both male and female interviewers were used. (Experience in Jamaica has shown that female interviewers are as effective as male interviewers at interviewing male respondents). Training for field work for both the pretest and the main surveys was the responsibility of STATIN, with the assistance of eight local trainers for the technical aspects. The Survey Director provided overall coordination of the training sessions, with the support of two CDC staff members. All trainers were professionals with extensive training and experience in the field of demography, epidemiology and survey taking. Officers of the National Family Planning Board, including the Medical Director and Liaison Officers, provided the interviewers with necessary training on contraceptive technology. Training on questionnaire editing was provided by the Survey Director, and the CDC for training in data entry, using an updated version of the SURVEY software they developed for survey data entry and editing on micro computers. Training for the field work was undertaken in two phases. The first phase was June 10-12,1997 for the pretest of the questionnaires and for survey procedures. The second series of training classes for the main surveys was carried out August 18-21, 1997, at four sites: Kingston, Oracabessa, Eltham, and Treasure Beach. This training consisted of classroom lectures, discussions, mock interviews and written tests. A total of 153 field personnel were trained. Of these, 22 were supervisors (14 males and 8 females) and 131 were interviewers (27 males and 104 females). One office clerk was included in the field training. 1.J FIELD WORK The organization of the field staff for administering the 1997 JRHS surveys was similar to that used for all other household surveys conducted by STATIN. The country was divided into four contiguous, nonoverlapping areas, each of which was managed by a senior supervisor. Within each area, there were four zones, each covering approximately 28 Primary Sampling Units. One supervisor and five interviewers were assigned to each zone. Pretest field work was conducted in a few preselected areas and lasted 3 days. The original schedule for the main survey was for 3 months of field work, beginning August 22, 1997. There were, however, a number of interruptions, including unusually heavy rains. Accordingly, field work was extended for 1 month, to the end of December 1997. 1.K RESPONSE RATES The household and individual status of interviews for both female and male samples is presented in 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 19 Chapter 1 - Background Table 1.1. Of the total number of 15,140 households selected in the female survey, there were 6,641 (43.9 percent) eligible respondents identified*; in the male survey, the number of eligible respondents was 2,470 (17.7 percent). Of the eligible households in the female survey, 12,124 questionnaires (80.1 percent) were completed; in the male survey, 11,159 questionnaires (80.2 percent) were completed. As was indicated, one respondent was selected from each eligible household. There were 6,384 completed questionnaires (96.1 percent) in the female survey and 2,279 (92.3 percent) in the male survey. All national results in this final report have been weighted to compensate for the over-sampling of smaller health regions and selection of one respondent per household already mentioned. However, unweighted numbers to be used for variance calculations are shown in each table. Results, however, are based on the weighted data. * An eligible household in the female survey is any household with the possibility of one or more females aged 15-49 years; in the male survey, there must be the possibility of one or more males aged 15-24 years. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 20 Chapter 2 - Characteristics of the Survey Population CHAPTER 2 CHARACTERISTICS OF THE SURVEY POPULATION 2.A GENERAL Age is the main background variable used to analyze the results of the survey and 5 year age cohorts have, in general, been used in this report. In studying young adults, however, 2 or 3 year age groups and where relevant, single years are presented. Other background variables used include education level, employment status, frequency of attendance at religious services, employment, area of residence, union status, parity, birth order, socio economic status, and others depending on the data being analysed. Although selected data for young adult males will be shown in this report, the emphasis will be on results pertaining to women 15-49 years of age. A second supplementary report will present results, in detail, for young adult females and males. 2.B AGE DISTRIBUTION OF THE SURVEY POPULATION The age distribution of the surveyed female population aged 15-49 years is presented in Table 2.1. Comparisons are given for the female population at the end of 1988, 1992 and 1996 (based on published demographic estimates) along with the results of the 1989 and 1993 Contraceptive Prevalence Surveys (CPSs). The age distribution from the 1997 JRHS for females in the 15-49 age group shows that directional movements over the period are consistent with lower fertility over time. Looking at the age distribution of the series, all age groups in the distribution for women fall within acceptable sampling error limits with perhaps fewer than expected young adults. There were minor discrepancies between survey and demographic estimates in several age groups. 2.C MARITAL AND UNION STATUS Marital or union status, regarded as one of the primary direct determinants of fertility in any population, may be used to identify the degree to which women of reproductive age are sexually active. In a population in which the most childbearing activities occur within unions, this can be approximated by nuptiality or by the proportion of time women spend in formal or informal unions. However, in Jamaica, as in many Caribbean countries, sexual unions occur not only in the context of legal marriage, but also in common-law and visiting unions, and particularly for young adults, within relationships that are not necessarily steady, such as having a boyfriend or a girlfriend with whom there is some sexual activity. Accordingly, a study of sexual activity must include not only 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 21 Chapter 2 - Characteristics of the Survey Population persons who are legally married but also those who are living in a sexual union or are sexually active. This report, therefore, is concerned not with the legality of a union, but rather with its status. Thus, the following four types of relationships are identified: a) Legally married - a union in which a woman or a man is legally married and lives with her or his spouse. b) Common-law - a union in which a woman or a man lives with a partner to whom she or he is not legally married. c) Visiting - a union in which a woman or a man reports having regular sexual relations with a partner with whom he or she does not live. d) Boyfriend/girlfriend - a relationship that does not fall in any of the three unions specified above, in which a woman or man reports having a relationship with someone of the opposite sex. There may or may not be sexual intercourse between the two partners. If there is, it is classified as boyfriend/girlfriend with sexual relations; if not, then the classification is boyfriend/girlfriend without sexual relations. Unless otherwise specified, "in union" includes categories (a), (b) and (c) and excludes category (d). Utilizing this breakdown, the union status of females covered in the surveys is shown in Table 2.2, by five year age groups. The patterns shown, both overall and by age group, are typical of that expected in the Jamaican female population. Twenty-five percent of women in the specified age group had no steady partner. Of the remaining, the highest proportion (29 percent) were in visiting relationships, a slightly lower proportion (24 percent) were in a common-law relationship, and 16 percent were legally married. In addition, 7 percent had boyfriends, and more than half of them reporting having sex with the boyfriend. The pattern by age group demonstrates the reality of the situation. Of those in the 15-19 age group, fewer than one percent were legally married and living with their husband; this was true of only four percent in the 20-24 cohort. The percentages increased among older women up to age 40-44. The fall in the percentage in the 45-49 age group can be accounted for by the higher possibility of divorce among older age groups as well as the observed phenomenon of women outliving their partners. A third factor is that at these older ages, some women move out of legal relationships into less stable relationships such as common-law and / or visiting relationships. The pattern among women in common-law relationships was somewhat different. The relatively low proportion (7 percent) of 15-19 year old women in a common law union demonstrates that unions 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 22 Chapter 2 - Characteristics of the Survey Population are more likely to be started in the older age groups.1 The lower percentage of women in common- law union after age 30-34 illustrates that longstanding common-law unions tend to become more formalized, thus adding respectability to these relationships. Visiting relationships were more prevalent among the young, as nearly 25 percent of women 15-19 years old were in this type of union. The proportion increased to 43 percent among those in the age group 20-24 years and fell off to fewer than 19 percent of women over age 40. The eight percent who had boyfriends were mainly in the younger age groups. Table D below compares the distribution of relationships found in 1997 with those found in 1993.2 As in Table 2.2, the data in this table represent not only those "in union" but those with a boyfriend, with or without sex as well as those with no steady partner. On the whole, the relationship patterns of female respondents remained fairly steady, although some variations have occurred over the 4 year period. Whereas there has been practically no change among women in a union (68 percent in 1997 compared with 70 percent in 1993), the proportion of legal unions appear to have increased slightly (16 percent in 1997 from 13 percent in 1993). Table D Percent Distribution of Women Aged 15-49, By Current Union Status 1 2 Although it should be noted that this percentage is well above the under one percent of unions in which the woman is legally married and is living with her husband. Whereas coverage in the 1997 JRHS is for women aged 15-49 years, that for 1993 was for women aged 15-44 years. The changes in relationships between those women 40-44 and those in age group 45-49 years old should be considered when comparing the percent distribution in the 2 years. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 23 Chapter 2 - Characteristics of the Survey Population 2.D EDUCATIONAL LEVEL Educational is another important variable associated with fertility and rates of growth in a population, because education levels attained are known to influence attitudes towards and perceptions about contraception and family size. For the purposes of the survey, education level was defined by years of schooling completed, shown by 5 year age groups for females aged 15-49 years in Table 2.3. Only 0.2 percent of female respondents had no schooling and a further 0.7 percent did not specify whether they had received any schooling. The number of years of schooling varied by age group. With the exception of the 15-19 age group, of whom a certain proportion had not yet completed their education, the data show that younger respondents received more schooling than older respondents. 2.E EMPLOYMENT STATUS Economic activity is another factor that influences attitudes and practices that affect fertility. In this context, the employment status of women is examined. Classification by age group is presented in Table 2.3. A further classification of employment status is presented in Table E: Table E Percent Distribution of Women Aged 15-49 Years By Employment Status And Age Group 1997 JRHS The above table and Table 2.3 show that under 12 percent of women in the 15-19 age group were employed, with the percentages generally increasing thereafter. With greater age, there was a gradual increase in the percentage of women working away from home; this was most evident among those 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 24 Chapter 2 - Characteristics of the Survey Population working full-time. However, the increase in the proportion of women working as age increased was perhaps most evident among those working way from home. This increased from fewer than 10 percent of women in the 15-19 age group to over 40 percent at older ages. Unemployment was greater among younger women. Table F presents a more detailed total percent distribution of respondents in each employment category: Table F Percent Distribution of Women Aged 15-49 Years 2.F RELIGION Religious beliefs and affiliations play a part in fertility behaviour, although the influence of religion appears to be lessening with the rise of other competing interests. Available data (not shown) demonstrate shifts in membership away from more traditional denominations towards non-traditional churches which are more revivalist in nature. This development, which may contribute to a lessening of the influence of membership in particular churches on attitudes and behaviour, would mean that frequency of attendance at any church is a more appropriate variable to use when studying reproductive health attitudes and practices. For this reason, frequency of attendance at religious services is the background religious variable used in the report, as indicated in Table 2.3. These data show that one third of all respondents attended religious services at least once per week, but older 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 25 Chapter 2 - Characteristics of the Survey Population women attended church more often than younger women; almost half of women over the age of 40 attended church one or more times per week. Contraceptive use patterns differ according to church attendance, as discussed later in the report. 2.G CHILDREN EVER BORN Table 2.3 presents the percent distribution of women aged 15-49 years by number of their live births as reported in the 1997 JRHS. As expected, the highest proportion of women who had no children (79 percent) were in the 15-19 age group and this percentage fell with increasing age. Few women aged 15-19 (17 percent) had even one live birth. As Jamaica is not country with high fertility, only over the age of 35 did a significant percentage of women have four or more live births. Comparisons with the 1993 JCPS were made for women aged 15-44 years, as indicated in Table G. As might be expected, there was little change in the percent distribution between the two surveys. Table G Percentage Distribution Of Women Aged 15-44 Years By Parity 1997 RHS, 1993 JCPS 2.H SOCIO ECONOMIC INDEX A further classification used to analyse the respondent population is socio economic index, based mainly on the types of possessions in the respondent's household, but also including the number of rooms in the house, the presence of piped water and toilet facilities, and years of education completed by the respondent. The survey population was divided into three categories for the purpose of the socio economic index: high, medium and low. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 26 Chapter 3 - Fertility and Related Factors CHAPTER 3 FERTILITY AND FERTILITY-RELATED FACTORS 3.A AGE AT MENARCHE AND SEXUAL EXPERIENCE All female respondents were asked: "How old were you when your first period started (first started menstruation?)". The results in Table 3.1 show the mean age at the first menstrual period (menarche) was just over 13 years. This continued the decline in the age at menarche which has been observed in Jamaica and other countries, and which is due, no doubt, to improvements in nutrition and health in general. In the past 30 years the mean age at menarche in Jamaica has fallen, as women currently aged 15-19 had their first period at 12.7 years, compared with 13.8 years for women currently aged 45-49 years. Mean age at menarche also declines as education levels increase, possibly because women in higher education categories have better health and nutrition, but also may attributable to the fact that women with more education were younger than less educated women. Table 3.2 presents data for 1997 and 1993 on women who reported that they ever had sexual relations, by age and frequency of church attendance. Eighty-eight percent of women in both 1997 and 1993 reported that they had sexual relations. As may be expected, there was some variation by age. In 1997, just over fifty percent of women aged 15-19 had sexual experience; in 1993, the proportion was 59 percent. In both 1997 and 1993, 90 percent of women 20 years of age and over had sexual experience; the percentage increased with age and approached 100 percent by age group 25-29. Classification by church attendance is shown for 1997 only; the greater the frequency of church attendance, the lower the percentage of women who have ever had sexual relations. Table 3.3, presents similar data for men aged 15-24. Eighty-five percent in 1997 and 84 percent in 1993 indicated they ever had sexual relations. As was the case for women, the proportion of young men who had ever had sexual relations increased consistently with age and was inversely related to church attendance. Table 3.4 presents data on the age at which women's first sexual experience took place by 5 year age groups. This provides an indication of trends over time of the age at which women begin sexual activity. Reporting by the youngest age groups is incomplete because their time of exposure was partially truncated. The median age at first sex is 17.3 years, varying between 16.9 and 17.5; they are only minor variations and they are not statistically significant. Percentages having had sexual relations before the indicated ages also show minor differences by age group. Therefore, the age at which women had their first sexual experience has changed little over 30 years. Table 3.4 also 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 27 Chapter 3 -Fertility and Related Factors provides information on age at first birth by current age. Results from this panel show that younger women may be delaying childbearing; only one-third of 20-24 year old women report a first birth by age 20 compared to almost 50 percent or more of older women. 3.B BREAST-FEEDING AND POSTPARTUM INSUSCEPTIBILITY Breast-feeding has two notable effects that make it important to include in surveys of reproductive health. First, breast-feeding can improve the health of infants, mainly through ensuring adequate nutrients and providing maternal antibodies to prevent disease in newborns. Second, by delaying the return of ovulation, breast-feeding increases the length of the interval between pregnancies. Among women who had a live birth in the 5 years preceding the date of the interview, 97 percent breast-fed their most recently born child (Table 3.5), a slight increase from the 94 percent reported in the 1993 survey (data not shown). Differentials according to age, health regions, education and residence in the proportion breast-fed were small. The mean duration of breast-feeding, calculated by examining proportions of infants currently breast- fed according to their age, was 13.1 months, slightly higher than the 12.4 months observed in 1993, which was virtually unchanged since the 1989 survey (data for 1993 and 1989 not shown). Differences in mean duration between most population subgroups were greatest according to residence; lower mean duration was observed in the Kingston Metropolitan Area (12.1 months) than in rural areas (13.7 months). However, the mean duration of exclusive breast-feeding fell for the population as a whole in 1997: 1.0 months compared with 1.7 months in 1993. It was also lower for every subgroup of the population. This indicates that even though Jamaican women typically breast- feed for about 1 year, they usually start giving their babies liquids other than breast milk at a very early age, so the period of exclusive breast-feeding is in fact decreasing. This early introduction of other liquids tends to reduce the intensity of breast-feeding, thereby reducing the health benefits of breast-feeding and shortening the amenorrhoeic period. The length of time it takes for a woman to again be at risk of pregnancy after the birth of a child, known as the postpartum insusceptible period, is determined primarily by the duration of postpartum amenorrhea (which is governed to a considerable degree by the length and intensity of breast- feeding) and the timing of the resumption of sexual intercourse. Table 3.6 presents the proportion of women who gave birth within 2 years of the interview who were still breast-feeding, who were still amenorrheic, and who had yet to resume sexual intercourse, according to time since the birth. Anyone who was still amenorrheic or was still sexually inactive was considered to still be in the postpartum insusceptible period. The proportion of women in all of categories declined rapidly after the first 2 months postpartum (Table 3.6). For example, 83 percent were postpartum amenorrhoeic at 0-2 months; at 3-4 months, 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 28 Chapter 3 -Fertility and Related Factors the proportion was only 45 percent, and this fell to 4 percent by 19-24 months. The mean duration of amenorrhea was only 5.6 months after a live birth. Although 93 percent of women with births in the preceding 2 months had not resumed sexual intercourse, few women were still sexually inactive within 2 years. Because of the generally quick return of the menses and the lack of prolonged postpartum abstinence, the mean postpartum insusceptible period tends to be short, at 8.7 months. The estimated mean length of the insusceptible period increased since 1993 when it was 7.2 months (1993 data not shown). This can be compared to the decrease from 1989, when the mean was 9.0 months. Table 3.7 displays percentages of women with births in the preceding 2 years who were still breast- feeding, amenorrheic, sexually active, and in the postpartum insusceptible period. Unlike the findings in 1993 (data not shown), the length of amenorrhea and therefore the insusceptible period in general, decreased with age. Other characteristics showed no particular pattern. Female respondents were asked their opinion as to the age a child should be before the mother stops breast-feeding; i.e., the ideal breast-feeding duration. Seventy percent of women were of the opinion that children should be breast-fed at least 7 months, little changed from the corresponding percentages for 1993 (Table 3.8). This corresponds to actual breast-feeding practices in Jamaica since, as seen earlier in Table 3.6, sixty-nine percent of women who had a birth in the past two years were still breast-feeding when their child had reached 7-8 months of age. There was little difference in women's perception of the ideal breast-feeding duration according to their characteristics, except that younger women (and women not currently in a union) were less likely to have an opinion on the ideal breast-feeding duration, no doubt due to larger proportions of this group being nulliparous and, therefore, having no experience with breast-feeding. 3.C CURRENT SEXUAL ACTIVITY Fifty-three percent of women reported that they had sexual intercourse at least once in the past month, that is, were sexually active (Table 3.9). This percentage varied by relationship status. More than 80 percent of married women and women in a consensual union were sexually active. This percentage dropped to 66 percent for women with a visiting partner and 54 percent for women with a boyfriend. Fewer than three percent of women with no steady partner reported sexual activity in the past 30 days. Differences in these data between 1993 and 1997 are minimal (1993 data not shown). Sexually active women were about their relationship with their last sexual partner (Table 3.10). Almost all legally married women (99.5 %) and women in consensual union (93 percent) said their last sexual partner was their spouse. In the case of women in a visiting relationship, 87 percent had their last sexual intercourse with a visiting partner, whereas of those with a boyfriend with whom 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 29 Chapter 3 - Fertility and Related Factors they were having sex, 91 percent had their last sexual intercourse with their boyfriend. Compared with 1993, in 1997 a higher percentage of women in visiting relationships and with boyfriends had their last sexual encounter with those partners (1993 data not shown). Those women who had not engaged in sexual intercourse in the past 30 days, that is, were not sexually active, were asked if they had sexual intercourse in the past three months. Thirty-five percent responded positively (Table 3.11). However, there was a great deal of difference between those in union or with a boyfriend, of whom more than half reported sexual intercourse in the past three months, and those with no steady partner, of whom only 8 percent had sexual relations in the past three months. As was also seen in Table 3.9, few women without a steady partner engaged in even casual sexual relations. Among young men aged 15-24 years, overall 48 percent were currently sexually active (Table 3.12). Almost half the young men in this age group have no steady partner, and relatively few of these men, 10 percent, are sexually active. On the other hand, most young men in this age group who are in union (married or common law) are sexually active, as are almost two-thirds of those with a girlfriend. Among young men in a marital or common law union, however, only two-thirds had their last sexual act with their partner, and even fewer young men in a visiting relationship (41 percent) had their last sexual act with their partner (Table 3.13). Interestingly, this figure rises to 78 percent of young men with a girlfriend with whom they were having sex. 3.D FERTILITY RATES Age-specific fertility rates (ASFR) and the total fertility rate (TFR), calculated for the two years prior to each survey, are displayed in Table 3.14 and Figure 1 for the years 1975, 1983, 1989, 1993 and 1997. The TFR of 2.8 for 1997 is lower than the TFR of 3.0 calculated for the 1993 survey, which was not a significant change from the rate of 2.9 found in 1989. Not only did the TFR remain relatively constant, but with the exception of the 25-29 year olds, none of the ASFRs exhibited any substantial change between the two surveys. This lack of evidence of an overall decline in fertility since the late 1980s comes as somewhat of a surprise in light of the considerable increase in the contraceptive prevalence rate (CPR). This apparent leveling off of rates of childbearing comes after a period of rapid fertility reduction between the early 1970s and the late 1980s, when the TFR fell by about one-third. Despite the apparent lack of change in fertility, the TFR for 1997 was very close to what would have been expected for a country with Jamaica's CPR (Robey et. al., 1992). The TFR reported for 1989 was slightly below what would have been expected with the CPR that existed then. It appears, then, that an explanation for the low 1989 fertility rate being may be needed, rather than an explanation for the 1993 and 1997 rates. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 30 Chapter 3 - Fertility and Related Factors Both total fertility and age specific fertility rates were lowest in the Kingston Metropolitan Area and highest in rural areas (Table 3.15). In Jamaica, approximately one-third of all women aged 15-49 are childless (Table 3.16). As expected, the percentage of women who are childless decreases sharply as age increases. Four-fifths of women under the age of 20 are childless and nearly two-fifths of those 20-24 years old are childless. Fewer than 10 percent of women aged 35 and older are childless. There is little difference in childlessness according to residence, but less educated women and women in lower socio economic categories are not as likely to be childless as those in higher categories. There are higher percentages of childlessness among women who regularly attend church than among those who attend with less regularity. These data are virtually unchanged since 1993 and 1989 (data not shown). 3.E PLANNING STATUS OF LAST PREGNANCY A measure of the success of women and men in having their desired number of children when they want to have them, is the planning status of their children. Questions on planning status referred to their last pregnancy. All female respondents who had a birth within 5 years of the interview were asked the following about the planning status of their last pregnancy. " When you became pregnant, did you want to become pregnant?" If not, "Was it that you wanted no more children, or that you just wanted to wait longer before another pregnancy?" On the basis of responses to these questions, each last birth to a woman in the past 5 years was classified as "planned", "mistimed", "unwanted", "unplanned, unknown status" (not known whether mistimed or unwanted) or unknown. Planned births were defined as those that were wanted; mistimed were classified as those that were wanted but at some time in the future; and unwanted births were those not wanted, even at a future time. With this scheme, the mistimed, unwanted and unplanned, unknown birth status can be combined as an estimate of unplanned births. According to the above definitions, 34 percent of pregnancies in the 5 years preceding the interview were planned, which was higher than the 29 percent of pregnancies reported as planned in 1993 and the 25 percent reported in 1989 (Table 3.17 and Figure 2). Over 40 percent of pregnancies in the past 5 years were reported to be mistimed and another 19 percent were unwanted. (It should be noted that this does no include pregnancies that did not result in a live birth. If there were a large number of induced abortions, the proportion of pregnancies that were planned would be even lower.) Unwanted pregnancies are positively associated with age and the number of living children (half of births to women who are at least age 40 or who had four or more children were unwanted). The majority of pregnancies of women under 29 years are mistimed. This percentage decreases rapidly as age increases, as the percentage of unwanted pregnancies increases. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 31 Chapter 3 - Fertility and Related Factors Unwanted pregnancies were inversely related to education; 27 percent of pregnancies to women with 0-9 years of schooling were unwanted, compared with 16 percent to women with 13 or more years of schooling. The pattern was similar for socio economic status, as the last pregnancy of 27 percent of women in the lowest socio economic index category was unwanted, compared to 9 percent of women in the highest category. Over half (57.5 percent) of last pregnancies of married women were planned, which is much higher than the proportion of planned pregnancies for women in less stable relationships (28-35 percent). Most births to women in a visiting relationship or a less stable relationship were mistimed (52-53 percent), reflecting the fact that, overall, these women were also younger than married women. With the relatively high contraceptive prevalence rate in Jamaica, these high proportions of mistimed and unwanted pregnancies are worrisome. Table 3.18 is a percent distribution of the number of children women want at the time of interview according to their current number of live births. Overall, nearly half wanted no more children, 18 percent wanted one or two children, and very few wanted three or more children. As expected, the number of additional children desired decreases with the current number of live births and suggests a movement towards a two-child family. Sixty percent of women with no live births reported they wanted one or two children, two-thirds with one child wanted one or no children and most women with two or more live births wanted no children. The greatest proportion of respondents, 44 percent and unchanged since 1993, think a woman should be aged 20-24 before she is responsible enough to have her first child (Table 3.19). Less than 20 percent of respondents think younger women are old enough for this responsibility, a proportion which drops to less than 10 percent among highly educated women. Otherwise, there is little variation of this opinion according to respondent's characteristics. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 32 Chapter 4 - Reproductive Health CHAPTER 4 REPRODUCTIVE HEALTH 4.A MATERNAL HEALTH AND CHILD CARE The importance of receiving prenatal care during pregnancy is well recognized and has been emphasized in government programmes to reduce infant mortality and to maintain or improve the health of mothers. Overall, prenatal care was virtually universal as 99 percent of all pregnancies to respondents in the past 5 years received some degree of prenatal care (data not shown). Table 4.1 presents a percent distribution of the source of prenatal care in the 5 years preceding the survey compared with data from the 1993 and 1989 surveys. About 80 percent of respondents' pregnancies received antenatal care in government clinics or hospitals; the remaining 20 percent were cared for by private doctors or in private hospitals. Between 1993 and 1997, the utilization of government institutions appears to have stabilized at 80 percent after a movement toward private sector sources of prenatal care beginning in 1989. (The 1989 JCPS found only 11 percent of pregnancies were cared for by private sources and 88 percent received care in government facilities.) Private sector sources of prenatal care are used to a greater extent by older women, lower parity women, and women who are better educated and in higher socio-economic groups. They are also used to a greater extent in the Kingston Metropolitan Area (Table 4.2). In the past 5 years women made at least five prenatal visits for more than 87 percent of their pregnancies (Table 4.3). The greatest number of prenatal visits were made by women in the Kingston Metropolitan Area and other urban areas, as more than 90 percent of pregnancies in these areas resulted in six or more visits, compared with less than 70 percent in rural areas. Fewer prenatal visits were made for pregnancies among women in lower socio-economic groups and women of higher parity (who tend to be in the lower socio-economic groups). Efforts at encouraging women to obtain complete prenatal care must be directed towards rural women in lower socio-economic categories Table 4.3 also presents data on the number of prenatal visits according to birth order. A slightly higher percentage of women had six or more visits at lower birth order, perhaps because first pregnancies are considered to be higher risk. Table 4.4 presents the month prenatal care began for most recent pregnancies resulting in live births in the past 5 years. Prenatal care for nearly 60 percent of these pregnancies started in the first 3 months, 27 percent by the end of the 5th month and 9 percent in the 6th to the 9th month. With respect to residence, prenatal care tended to begin earlier in the Kingston Metropolitan Area (64 percent in the first trimester) although the percentage in the parish of Kingston is relatively low (50 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 33 Chapter 4 - Reproductive Health percent). Parishes whrer this proportion was more than 60 percent were St. Thomas, Westmorland and St. Catherine. Parishes where proportions were below 50 percent were Trelawny, Portland, St. Elizabeth and St. Mary. The percentage of pregnancies for which prenatal care began in the first 3 months differed by socio economic status; only 49 percent of pregnancies in the low socio economic group compared with 58 percent in the medium group and 70 percent in the high socio economic group. Birth order also had an impact; for 61 percent of pregnancies of birth order 1, prenatal care was started in the first 3 months; this percentage fell to 51 percent for the 5th and higher birth order. This may be due to women being complacent about higher birth order pregnancies as well as higher birth order women being most often in lower education and socio economic groups. Table 4.5 indicates the percentage of pregnancies to women 15-49 years in the past 5 years that were classified as high risk according to Ministry of Health age and parity criteria.3 Twenty-one percent of pregnancies were considered high risk. Of these, the lowest percentages were in the Kingston Metropolitan Area (19 percent) and other urban areas (18 percent), and the highest (23 percent) were in rural areas. Parishes with the lowest percentages were as follows: Kingston (17 percent), St. Catherine (18 percent), St. Mary (18 percent) and St. Ann (19); St. James had the highest percentage (27 percent). Women in the lowest socio economic group were found to be at highest risk and those in the highest group were at lowest risk. In terms of birth order, the relatively high percentage for birth order 1 reflects the high proportion of women under 17 years old who are in this group; this is also true for birth order 5+ because of the high proportion of women over the age of 30 in this group. How well do prenatal care services deal with high-risk pregnancies? Table 4.6 presents the percentage of all pregnancies and high-risk pregnancies for which the timing and the number of prenatal care visits was inadequate.4 The timing and/or the number of visits during prenatal care was inadequate for one-third of all pregnancies and for two-thirds of high-risk pregnancies. With respect 3 In Jamaica, pregnancies of women 16 years old or less at the time of conception or 30 years or more with no previous pregnancies, 35 years old with 2 or more previous pregnancies or more than 5 pregnancies at any age are considered to be "high risk". There are other criteria not measured by this survey. 4 The Ministry of Health criteria are as follows: 1. Prenatal care must begin by the 4th month; 2. For low-risk multiparous women (with more than one parity), a minimum of 6 visits; for all high risk pregnancies, a minimum of 10 visits. 34 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY Chapter 4 -Reproductive Health to all pregnancies, St. Andrew (24 percent) and St. Catherine (23 percent) had the lowest percentages while Kingston (41 percent), St. Thomas (43 percent), Portland (47 percent), St. Mary (47 percent), Trelawny (47 percent) and St. Elizabeth (49 percent) had the highest. For over 70 percent of pregnancies conceived before age 17, the number or timing of visits during prenatal care was inadequate, as were nearly 60 percent for those conceived between ages 35 and 45. Also, women of low socio economic status were more likely to have inadequate prenatal care for all pregnancies as well as high-risk pregnancies. As might be expected, women at the lowest and highest birth orders were more likely to have inadequate prenatal care according to the criteria. What is the adequacy of the number of visits for prenatal care for high-risk pregnancies? As shown in Table 4.7, only 34 percent of high risk pregnancies had an adequate number of visits for prenatal care, a further 30 percent had a partially adequate number of visits, and for 36 percent of the pregnancies the number of visits was not adequate 5. Women in the Kingston Metropolitan Area with high risk pregnancies are slightly more likely to have an adequate number of visits for prenatal care than those who live in other urban areas and are much more likely than those in rural areas. This is also true when the numbers defined as "fully adequate" and "somewhat adequate" are combined. Thus, 44 percent of high-risk pregnancies in rural areas had an inadequate number of prenatal visits, compared with 24 and 27 percent in the Kingston Metropolitan Area and other urban areas, respectively. Only in St. James, St. Catherine and St. Andrew did a majority of high-risk pregnancies have a fully adequate number of prenatal visits; in Portland and St. Mary, the percentages were below 10 percent. Not unexpectedly, the percentage of adequate prenatal visits for high-risk pregnancies is higher as the socio economic index rises. Also, the level of adequacy rises with each additional birth to birth order 3, but falls thereafter. For normal risk pregnancies, 29 percent of first pregnancies and 27 percent of subsequent pregnancies did not have an adequate number of visits for prenatal care (Table 4.8).6 Place of residence had some influence, particularly among first pregnancies, where the degree of inadequacy 5 The criteria for high risk pregnancies established by the Ministry of Health are as follows: a. Prenatal care must begin by the 4th month of pregnancy; b. Six to nine visits are considered to be moderately adequate; c. Ten or more visits are considered fully adequate. 6 The number of visit criteria established by The Ministry of Health for normal risk pregnancies are: a. For first pregnancies, a minimum of six visits; b. For subsequent pregnancies, a minimum of five visits. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 35 Chapter 4 - Reproductive Health in the Kingston Metropolitan Area was lower than in other urban areas and much lower than in rural areas. Women in the lower socio economic groups were more likely to have an inadequate number of prenatal visits. The percentage of ever pregnant and currently pregnant women aged 15-49 years who smoked cigarettes and/or drank alcohol during their last or current pregnancy is indicated in Table 4.9. It is encouraging that a relatively small percentage of ever-pregnant women smoked or drank during their last or current pregnancy (4 percent smoked, 8 percent drank). The differentials according to residence and age at conception are minimal except perhaps in the case of smoking, for women who conceived between age 35-45 years, where the percentage of smokers was higher. The differentials according to socio economic status and years of education are consistent, with the likelihood of smoking and drinking among the lower level groups is higher than among those in the higher level groups. A number of procedures are carried out during prenatal care. Two of these are checks on blood pressure and administration of antitetanus vaccinations. Table 4.10 indicates that among those women whose blood pressure was checked during their most recent pregnancy in the past five years, 14 percent were told twice their blood pressure was high. There were no differences according to residence, health region or socio economic index. There were some differences by parish, as 20 percent of women in Kingston reported high blood pressure, compared with fewer than ten percent of women in St. Thomas, Hanover and St. Mary. As might be expected, the proportion of women with high blood pressure is directly related to age at conception. Tetanus is a major killer of newborns throughout the world, but it is preventable. Two doses of tetanus toxoid vaccine given 1 month apart during pregnancy prevent tetanus in both mother and the newborn child. Table 4.11 indicates that 77 percent of pregnant women in the past 5 years had been given one or more antitetanus injections. There appears to be no marked variation except by parish; St. Catherine had a relatively low percentage (62 percent), whereas parishes with the highest percentages were Portland (85 percent), Kingston (86 percent), Hanover (87 percent) and Westmorland (88 percent). The proportion of babies delivered in medical facilities is important. Table 4.12 presents data on place of delivery by type of institution and by selected characteristics. The institutions are broken 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 36 Chapter 4 - Reproductive Health own into teaching hospitals, 7 regional hospitals, 8 other government hospitals, homes,9 private medical facilities and other facilities. 10 Thirty percent of deliveries in the past 5 years were in a teaching hospital; a further 26 percent were in regional hospitals and 27 percent in other government hospitals. Thus, over 80 percent of births to women 15-49 in the 5 years preceding the survey were in a government hospital and less than 10 percent were at home. In general, most parishes followed this pattern, with the exception of St. Ann, where 12 percent were delivered in a private medical facility. More home deliveries occurred in rural areas and among women whose socio economic index was low as well as in six parishes where 10 percent or more of births at home. Also, the likelihood of home deliveries increased with birth order, presumably because most of these births were to rural or lower socio economic level women. Table 4.13 presents data on who attended the births of children born in the preceding 5 years. Ninety- five percent of births were attended by a doctor, trained nurse or trained midwife. As may be expected, births among women in higher socio-economic categories, particularly in the Kingston Metropolitan Area, were the most likely to be attended by a doctor. Although very few (less than 4 percent of births) were attended by a "nana" (traditional birth attendant), these births were more likely to be among "other urban" and rural women in lower socio-economic categories and among women with birth order 5 or more. 4.B CANCER SCREENING The survey included questions on two types of cancer screening: cervical cancer by taking a pap smear and screening for breast cancer by the respondent doing a breast self-examination. Table 4.14 presents data on pap smears. Although one in two women had ever had a pap smear, only about one in four had one in the past 2 years and one in 6 in the past year. There is little difference by age, except relatively few women under 20 had a recent pap smear. There is, however, a marked difference according to education and socio economic level. More than twice as many women in the "high" socio economic or education categories as women in the lowest categories had a pap 7 8 9 10 These include the Victoria Jubilee Hospital, the University Hospital of the West Indies and the Cornwall Regional Hospital. These include the Savanna-la-mar Hospital, the Mandeville Hospital, the St. Ann's Bay Hospital and the Spanish Town Hospital. These includes the respondent's home and the home of a friend or relative. "Other facilities" include rural maternity centres, most of which are government owned. There is, in particular, one relatively large privately owned rural maternity centre in St. Elizabeth. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 37 Chapter 4 - Reproductive Health smear in the past year. There was also a striking difference by parish, ranging from 20 percent of women in St. James to only 7 percent of women in St. Mary. Respondents were asked if they had ever been taught by a health professional to do a breast self- examination, if had ever done one and if they had done one in the past year and in the past month. Table 4.15 shows that 34 percent of all women aged 15-49 reported that they had been taught to do a breast self-examination, but more than half indicated that they had at some time done such an examination, meaning that some women had learned to do the exam from some other source. Of those who had ever done a breast self-exam, the great majority had done one in the past year. Twenty-eight percent of women had performed an exam in the past month. In the case of respondents with breast cancer in their family, higher percentages were reported for all four categories. The proportion of women had been taught to do a breast self-examination increased up to age 25-29. For those who had ever done the self-examination or who had done one in the past year, the peak was is in the 30-34 age group. Socio economic status appears to have some effect; lower percentages were observed in all categories for those who were in the lower socio economic group compared with those who were in the medium and high groups. Birth order appears not to have any effect on the level of screening for breast cancer. Two parishes, Westmorland and St. Mary, had particularly low percentages of women who had performed a breast self-examination in the past year. 4.C FORCED SEXUAL INTERCOURSE Sexually experienced female respondents were asked if during their lifetime they had ever "been forced to have sexual intercourse". Twenty percent reported they had been forced to have sex at least once (Table 4.16). Despite the fact that respondents were asked to report forced sex during their entire lifetime, younger women reported forced sex to a greater extent than older women, as twenty- six percent of women aged 15-19 reported having been forced to have sex, which decreased to 11 percent of women aged 45-49. This may indicate a trend toward forced sex becoming an increasingly common phenomenon or, alternatively, that younger women are more forthcoming about reporting forced sex. There is also a slightly greater tendency for women in lower socio economic and education categories to report forced sex. Respondents were next asked who the last person was who forced tham to have sex. Table 4.17 shows that for the most victims, about 80 percent, the last perpetrator was someone known to them rather than a casual acquaintance (12 percent) or an unknown rapist (6 percent). In fact, 38 percent of perpetrators were union partners (married, common law or visiting partner) of the victim. Moreover, one-third of victims who were currently married or in a visiting relationship and 43 percent of those in a common law union reported that the perpetrator was their partner at the time. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 38 Chapter 5 - Contraceptive Knowledge CHAPTER 5 CONTRACEPTIVE KNOWLEDGE 5.A KNOWLEDGE OF CONTRACEPTIVE METHODS The population of Jamaica has been exposed to widespread contraceptive education for some 30 years, which is reflected in the extent of knowledge of contraceptive methods. Table 5.1 shows the percentage of women aged 15-49 who had heard of specific contraceptive methods in 1997, with comparisons for 1993 and 1989. As in earlier surveys, the results demonstrate that knowledge is almost universal. Ninety-nine percent had heard of the pill and condom in 1989, 1993 and 1997. Knowledge of the contraceptive injection, although high in 1989 (96 percent), has increased slightly to 99 percent in 1997. Knowledge of female sterilization exceeded 90 percent in 1997. The proportion who had heard of the withdrawal method increased from 59 percent of women in 1989 to 84 percent in 1997. On the other hand, knowledge of the IUD remained constant at between 83 and 84 percent. Although even lower overall, knowledge of other methods have all shown steady increases over the period, some more pronounced than others. The pattern of knowledge of contraceptive methods among young adult men is similar to that of women, but, with the exception of the condom and the pill, levels of knowledge are lower (Table 5.2). For young men, the level of knowledge of all methods has increased since 1993 with the exception of female sterilization. Most significant is the increased knowledge of male sterilization, Norplant, spermicides and injectables. The increased knowledge among young men may be due to increased use of these methods by women, but a publicity campaign promoting vasectomy also may have contributed to increasing awareness of contraception in general. Table 5.3 shows knowledge about specific contraceptive methods in 1997 by 5-year age groups. For the three most well-known methods (the pill, the condom and the injectable) there is little variation by age. In the case of female sterilization, which also has a high level of knowledge, there is a gradual increase with age, from 87 percent in the youngest age group to almost universal knowledge (98 percent) at ages 45-49. Table 5.4 presents knowledge about contraceptive methods according to place of residence. In general, knowledge is lower in rural than in other areas, particularly for the lesser known methods. Not shown in a table is that the pattern of knowledge by health region shows marked consistency, except that knowledge of the less well-known methods is lower in Health Regions 2 and 4 than elsewhere. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 39 Chapter 5 - Contraceptive Knowledge The level of knowledge among women has been further cross-tabulated by educational attainment and is presented in Table 5.5. Here it is shown that, with the exception of the most commonly used methods in Jamaica (pill, condom, injection and female sterilization), women with higher levels of education are more likely to have heard of specific methods. 5.B OPINIONS ON SPACING, PREGNANCY AND SEXUALITY Female respondents were asked their opinion on spacing of births; specifically "How old do you think a child should be before another child is born". Only four percent of women felt that there should be less than 2 years between births (Table 5.6). This has changed only slightly since 1993. The great majority of women, 90 percent, felt there should be at least 2 years between births and 40 percent felt that more than 4 years was the ideal birth interval. Older women were slightly more likely than younger women to feel between 2 and 4 years, rather than more than 4 years, was the ideal birth interval. Female respondents were asked whether they agreed with a number of statements regarding opinions on pregnancy, sexuality and attitudes toward life. As seen in the upper panel of Table 5.7, forty-five percent of respondents agreed with the statement "A girl can only get pregnant if she has seen her first period". Since it would be very rare for a young woman to ovulate prior to her first menstrual period, this means that more than half of the women interviewed are in doubt about when fecundity begins. Moreover, a greater percentage of less well educated women agreed with the statement than better educated women, the opposite of what would have been expected, raising the question of whether the statement was well understood during interviews. If the statement was well understood, the data show a lack of understanding among women in all education categories. Only 27 percent of women agreed with the statement "It is not necessary to use a condom with a steady partner", showing that almost three-fourths of women are aware of the value of condoms as a disease prevention measure even with steady partners. In spite of anecdotal information otherwise, very few women (less than 10 percent) agreed with the statements: "A girl must have a baby by the time by the time she is 18 years old"; "A boy must have sex to show that he is a man" and "A girl can avoid getting pregnant by having sex standing up, using Pepsi or going to the sea". The respondents who were more likely to agree with these "folk stories" were those who had the least education. With respect to attitudes toward life, the lower panel of Table 5.7 shows that regardless of educational level, almost 90 percent of women agreed with the statement "when you get what you want, it is usually because you worked hard for it". A high percentage of women also thought that they did not have to "conform to wishes of others" to get what they want, as 85 percent disagreed 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 40 Chapter 5 - Contraceptive Knowledge with that statement. Also, most women (82 percent) felt their life was not controlled "by people with more power" than they had themselves and 79 percent disagreed that "what others in your family want should always come first before what you want". In the above cases, better educated women were more likely to disagree with these statements. Although the first four responses in the lower panel of Table 5.7 seem to indicate that women believe that they have control over their life, responses to the next two statements contradict this confidence. (Note: the statements were not read in the order shown in Table 5.7). Only one-third of women agreed that they "can generally determine happens in their life" and only 29 percent agrees that "planning too far ahead is not wise since many things turn out to be good or bad luck". The inconsistencies in response to these "locus of control" statements merit secondary analysis. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 41 Chapter 5 - Contraceptive Knowledge 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 42 Chapter 6 - Contraceptive Usage CHAPTER 6 CONTRACEPTIVE USAGE 6.A EVER USE OF CONTRACEPTIVES Table 6.1 looks at women aged 15-49 who reported having ever used any contraceptive method and compares the information with 1993 data. In 1997, 80 percent of all Jamaican women aged 15-49 used a method of contraception at some time, which is almost identical to the 79 percent of women aged 15-44 in 1993. In 1997 ever use increased with age up to 30-34 years and declined slightly thereafter. As might be expected, ever use was lowest for the 15-19 age group. The lower use by 15-19 year olds is correlated with the approximately 50 percent ever use reported by women with no live births and/or no current partner in both 1997 and 1993. Although over 90 percent of women currently in a union (married, common law or visiting partner) ever used contraception, only 50 percent of women not currently in union (mostly young women) ever used a method. Ever use does not appear to be closely correlated with years of schooling. In 1997, however, women in the "low" socio economic group appeared more likely to have ever used contraception. In both periods frequency of church attendance appeared to have had some impact, with those attending with greater frequency having a lower tendency to have ever used a contraceptive. Ever use of specific methods is presented in Table 6.2 and the data for 1997 are compared with data for 1993 and 1989. In the most recent surveys, the modern method ever used by the most respondents was the condom (59 percent in 1997 and 53 percent in 1993); in 1989 it was the pill (48 percent). Ever use of withdrawal changed significantly over the period; from 14 percent of women in 1989, it rose to 20 percent in 1993 and increased to 29 percent of women in 1997. Further research into this change is warranted. The injectable, in third position in terms of ever use in 1989 and 1993, rose even further percentagewise in 1997. The use of female sterilization (between 10 and 11 percent over the period) remained fairly constant. Use of the remaining methods remained fairly consistent except for the calendar or rhythm method which moved from a low of 3 percent in 1989 to a high of 8 percent in 1993; it decreased to 6 percent in 1997. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 43 Chapter 6 - Contraceptive Usage 6.B INITIAL USE OF CONTRACEPTIVES The mean age at which women first used contraception is indicated in Table 6.3 according to a variety of social and demographic variables and is compared with the 1993 JCPS wherever possible. Overall, mean age at first use for women was just under 20 years in both years (19.5 in 1997 and 19.7 in 1993). Mean age at first use was fairly similar in all three areas. Mean age at first use is a function of age; the older the respondent, the higher is the mean age at first use. Most importantly, mean age at first use was lower in all age groups in 1997 than in 1993. This was also true with increasing parity; as the number of live births of respondents increased, mean age at first use rose in both periods. Therefore, mean age at first use appears to be decreasing over time. There was no significant difference in age at first use for the education or socio economic groups, but there were consistent reductions as the frequency of church attendance decreased. The distribution of women aged 15-44 years by number of living children when they first used contraception is presented in Table 6.4 for 1997 and 1993. In 1997, 54 percent of women aged 15- 44 years had no children when they first used a contraceptive method; 30 percent had one child and 16 percent had two or more children. In the comparative period in 1993, 48 percent had no children at first use, 31 percent had one child and 21 percent had two or more children. Thus, use was greater in 1997 than in 1993 for those who had no children, which means that women are starting to use contraception earlier in their reproductive years for spacing of births. This is consistent with the data in Table 6.3. Table 6.4 shows that the percentage of women who had no children when they first used a method was highest in the Kingston Metropolitan Area and lowest in rural areas. This percentage increased with higher levels of schooling and socio economic levels. There was no strong correlation with frequency of church attendance. 6.C CURRENT USE OF CONTRACEPTIVES Each respondent who reported they were currently using contraception was asked the following question:" Which contraceptive method are you or your partner currently using?" Respondents were also asked whether they or their partner simultaneously used another secondary method. The tables that immediately follow present only primary method use; the data on secondary method use are presented later in this section. Table 6.5 presents contraceptive use by relationship status for all women aged 15-49 years, irrespective of whether they were in a union. In all other tables in this section, the data presented are restricted to women and men currently in a union only. To reiterate what was mentioned previously, in the Jamaican context, "in union" is defined as being married, living in a common law 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 44 Chapter 6 - Contraceptive Usage union or having a visiting relationship. Those persons whose partner is a boyfriend or girlfriend or who have no current partner are considered to be not in union. As was shown previously, relationship status is, to a great extent, related to age, as younger men and women tend to be in a visiting relationships and as they become older enter into a common law union and then later into marriage. Therefore, many of the data on current contraceptive use that show differences by relationship status may also be influenced by age and other age-related variables, such as the number of live births. Results in Table 6.5 show that 50 percent of all women aged 15-49 were currently using a contraceptive method, compared to 48 percent of all women aged 15-44 in 1993. The most widely used method among all women was the pill (15 percent of women), followed by the condom (14 percent) and tubal ligation (10 percent). The slight increase in total use since 1993 is mainly due to the increase in use of injectables, which almost doubled in the 4-year period from 4.7 to 8.1 percent (p<0.05). Use of any method is about the same for the three types of union at 64, 66 and 67 percent of women who are married, in a common law union or in a visiting relationship, respectively. In addition, 62 percent of women with a boyfriend with whom they have sexual relations use some method. However, relatively few women with a boyfriend with whom they have no sex or women with no steady partner use a method of any kind. As mentioned above, the remaining data presented in this section are restricted to women who are currently in a union. Table 6.6 shows use of any contraceptive method by this group in 1997 and 1993. Overall, 66 percent of women in union were using a contraceptive method, compared with 62 percent in 1993. Usage increased in all but the 15 to 19 year old age group from 1993 to 1997. The pattern is similar by number of live births; use increased for all women except those who had no live births, who were largely young women. There was little variation by parish, with more than 70 percent of women using a method in Hanover and Trelawny; in most other parishes between 61 and 69 percent of women were using a method. The exception is St. Thomas where only 56 percent of women were using contraception. With respect to employment status, contraceptive prevalence is highest among students (83 percent) and lowest among homemakers (58 percent) (data not shown). For those working full time, the differential between those working outside the home and those working at home is minimal (70 percent compared with 68 percent). There is a marked difference, however, among part time workers, as the percent using contraception among those working part time outside the home is closer to that of those working full time (74 percent); for those working part time at home, contraceptive use approximates that of homemakers (56 percent). The unemployed have a relatively high prevalence rate of 70 percent. There is little variation in contraceptive use by women in a union 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 45 Chapter 6 - Contraceptive Usage according to education or socio economic level. Table 6.7 presents the trend of contraceptive usage by Jamaican women in union since 1983. Contraceptive use increased moderately between 1983 and 1989, rising from 51 percent to 55 percent of women in union, an increase of 8 percent. Use increased at a greater rate between 1989 and 1993 (55 to 62 percent), an increase of 14 percent. Between 1993 and 1997, the increase was 4 percentage points or 6 percent. The method mix among women did not change significantly during the 6 year period between 1983 and 1989. During that period, the most prevalent method used in Jamaica was the pill, followed by female sterilization, the condom and injectables. Change in condom use was relatively minor during those 6 years, increasing from 7.6 percent of women in a union in 1983 to 8.6 percent in 1989, an increase of only 13 percent. However, the rise in use of condoms between 1989 and 1993 (9 to 17 percent) was a much more dramatic increase of 86 percent, accounting for most of the increase in overall contraceptive use in this period. This increase also changed the method mix, as the condom became the second most prevalent method used by women in union. This large increase in condom use was, no doubt, due in part to the increased fear since 1989 of sexually transmitted diseases (STDs) especially AIDS. Between 1993 and 1997, changes were minimal in all specific methods used except for injectables, the use of which increased by 76 percent, from 6 percent of women in union to 11 percent. Other than those already mentioned, the use of other methods is minimal in Jamaica. Table 6.8 indicates the percentage of women 15-49 years old who, in 1997, were currently using any contraceptive method, any modern method or any traditional method, by selected characteristics. As indicated previously, the 1997 contraceptive prevalence rate was 65.9 percent. Overall, 62.8 percent were using a modern method11, which, as shown in the right-hand column, represents 95 percent of all users. An additional 3 percent were using a traditional method12. There was no significant pattern by parish because in all parishes over 90 percent of women using any method were using a modern method. Table 6.9 and Figure 3 present contraceptive use for 1993 and 1997 by age group and method for women in a union. As indicated, 66 to 69 percent of women aged 20 to 44 were using a 11 12 Defined as including female and male sterilization, injection, pill, IUD, condom, spermicides and diaphragm. Included are withdrawal and natural methods such as calendar or rhythm and Billings methods. 46 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY Chapter 6 - Contraceptive Usage contraceptive method. The proportion of 15-19 year old women who were using a method has not increased since 1993. Looking at specific methods used, in general, as in 1993, as age increases women tended to use more effective methods. The most prevalent method used by women under the age of 20 is the condom, which was used by almost half the users in that age group. The pill was the most prevalent method used by women between the ages of 20 and 34 followed by the condom and injections. After age 35, female sterilization was the most prevalent method used, and by age 40 almost two thirds of women in a union using any method have been sterilized. The use of injectables followed the same pattern as the pill; use was highest by women in their middle reproductive years; that is, between ages 20 and 39. After age 40 relatively few women used injectables. Table 6.10 presents for 1997 the mean age of women using specific contraceptive method, with comparisons with 1993. The proportionate utilization of the different methods as age increased, as in Table 6.9, is evident in the mean age of users. Thus, the mean age for women who used condoms is lower than that of women who used the pill and injectables, and the mean age of women who were sterilized is almost 9 years older than those of pill and injectable users. The pattern was similar in 1993, but the mean age was slightly older for all methods in 1997. Among men aged 15-24 who had sexual relations in the last 30 days, 80 percent used a contraceptive method at last sexual intercourse, compared with 68 percent in 1993 (p<0.05) (Table 6.11). The patterns of contraceptive use among young men by age group are somewhat similar to those of women, except for a much greater overall use of condoms. Among young men, the second most prevalent method is the pill, as 12 percent of men reported in both 1997 and 1993 that their female partner used the pill The 1997 JRHS found that although contraceptive use among women did not differ significantly between health regions, the method mix varied somewhat (Table 6.12). In all four regions, the four methods most frequently used were the pill, condom, tubal ligation and injectables, in that order. However, use of the condom is lower in Health Regions 2 and 4, while use of injectables varies somewhat from 14 percent of women in union in Health Region 4 to 9 percent in Health Region 1. Compared with 1993, the largest increase in contraceptive use was seen in Health Region 3. The pattern of contraceptive use by parity was similar to that for age; contraceptive prevalence increased consistently as the number of live births increased and dropped slightly after three live births (Table 6.13). Similar to age, condoms were the major method (31 percent) for women with no live births (the youngest), and the pill was the major method for women with 1 or 2 live births. Sterilization was the method of choice for higher parity women, as one-third of all women with four or more births were sterilized. The injection was most heavily used by women with 2 or 3 live births, which demonstrates the movement to more long term methods with increasing parity. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 47 Chapter 6 - Contraceptive Usage Did their level of education of women influence their use of contraceptives? In answering this question account must be taken of the correlation between years of schooling and other factors such as age and parity, which would tend to affect the relationship. Overall, there was no significant difference in contraceptive use by education. Nevertheless, Table 6.14 indicates that condom use increased with education and that there was greater use of sterilization among those with less education. However, both of these observations may be influenced by the fact that younger women (who used condoms to a greater extent and sterilization to a lesser extent) were, in general, better educated than older women and less educated women tended to have higher parity, a group with greater use of female sterilization. There was a direct relationship between age and frequency of church attendance; older women were more likely than younger women to attend church services (see Table 2.3). This should, therefore, be considered when interpreting the results on contraceptive use by frequency of church attendance shown in Table 6.15. Hence, for example, those women who attended church services with greater regularity were more likely to make use of tubal ligation than the younger women who attended church services less. Also, pill and condom use were lower for those attending with greater regularity. In general, overall differences by frequency of attendance were not great, although those who attend most regularly had a slightly lower level of use. Not shown in a table is that there were no significant differences in contraceptive use by by parish. The pill is the most prevalent method in all parishes except Kingston, where condom use is highest. Contraceptive prevalence, as shown in Table 6.1 and subsequent tables, relate to the primary method used by the respondents. However, condoms were also used as a secondary method, which is important when analyzing contraceptive use, particularly trends over time13. The use of a secondary method together with the primary method, by women aged 15-49 years currently in union, is shown in Table 6.16. Among all contraceptive users, 88 percent were not using 13There are two factors in determining primary and secondary method use: the methods named by the respondent and re-coding during data processing. Interviewers were instructed that when a respondent reported using two methods, or where he/she is using one method and the partner another, to record the most effective method as the primary method, because information about secondary method use was obtained from a subsequent set of questions. If it was difficult to make a choice, the respondent was allowed to make the selection, since it was irrelevant which order the methods were reported, as errors were corrected by re-coding during data analysis. This final determination of primary and secondary methods was made by applying priority criteria based on effectiveness. The following were the classifications used, in descending order of effectiveness: a. Sterilization; b. Hormonal methods; c. Barrier methods; d.Other methods. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 48 Chapter 6 - Contraceptive Usage a secondary method, and condoms accounted for almost all secondary method use (11 percent of users of a primary method). Fewer than one percent of all users were using a secondary method other than condoms. Almost one-quarter of pill users (24 percent) also used condoms as a secondary method, followed by 14 percent of injection users. Six percent of sterilized women also used condoms, as did 9 percent of IUD users. In assessing condom use as a primary method by 17 percent of women in a union, supply managers and logisticians must therefore take note of an additional 11 percent of users for whom the condom was a secondary method. To summarize the above findings, overall contraceptive use was high for all socio demographic groups and does not vary greatly by age group. However, the choice of method does vary, with women and to a lesser extent, men, moving from the condom to the pill and then to female sterilization as they get older. As has been shown, the same is true of relationship status which, to a great extent, is related to age. Younger men and women tended to be in visiting relationships and, as they become older, entered into common-law unions, and later into marriage. Therefore, many of the data on current contraceptive use that show differences by relationship status, may also be influenced by age and other age-related variables, such as number of live births. 6.D SOURCE OF CONTRACEPTION The source of the four major contraceptive methods for women varied according to the method used (Tables 6.17 for 1997, Table 6.18 for 1993 and Figure 4 comparing 1997, 1993 and 1989). In 1997, women largely obtained their pills and condoms in pharmacies and to a lesser extent in government health centres, with urban users patronizing pharmacies to a greater extent than rural users. The most significant additional sources were shops and supermarkets for condoms, as 16 percent of condom users used these sources for purchasing condoms. Because they require medical intervention, almost all injections and female sterilizations were obtained from government health centres and government hospitals, respectively, and to an even greater extent in rural areas than in urban areas. As seen in Figure 4, the major difference in the sources of contraception since 1989 is that the trend has been toward greater use of pharmacies for pills, and pharmacies and shops for condoms, while use of government health centres has decreased. This signals a continued shift to the private sector as a source for these methods. The source of injections and female sterilization for women has been virtually unchanged since 1989. Table 6.19 looks at sources of the most prevalent contraceptive methods used by women aged 15-49 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 49 Chapter 6 - Contraceptive Usage who were not in union. The patterns were similar to those of women not in a union, though greater use was made of pharmacies and less use of government health centres than women in union. The shop or supermarket is also one of the main sources for condoms. While some government health centres and hospitals offer family planning services at any time, others only offer these services on certain days or at certain times. Respondents who named a government facility as their source were asked how services were offered there. Table 6.20 shows that less than half those using a government facility as their source could do so on any day and at any time. This percentage is lower in the Kingston Metopolitan Area, but much higher in Region 3. On the other hand, not shown in a table is that more than 90 percent of women whose government facility offered family planning services only on certain days or at certain times reported that the days or times were convenient for them. Almost one-third of women who have to travel to their source of contraception could reach the site in less than 15 minutes and a further third could do so in less than 30 minutes (Table 6.21). A greater percentage of women in rural areas must travel longer than 30 minutes to reach their contraceptive source, as presumably their sources are located at some distance in a village or town. Also, rural women may may have less access to personal or public means or transport. Conversely, fewer women in higher socio economic groups must travel more than 30 minutes to their source of contraception, no doubt because they have greater access to private means of transport. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 50 Chapter 7 - Hormonal Contraceptive Use CHAPTER 7 HORMONAL CONTRACEPTIVE USE 7.A PILL USE The pill is the most widely used method of contraception in Jamaica. It was considered useful, therefore, to explore more of the facts about pill use. Three marketing strategies relating to the pill are practice in Jamaica. The first is the public sector programme in government health facilities. The pills distributed through this system include Lo-Femenal and Ovral. The second programme is that in which distributors lower the price of some brands of pills available for sale in certain public and private sector outlets. This is the Social Marketing Programme, known as the "Personal Choice Programme", which sells the Perle and Minigynon brands of pill. The commercial sector sells non subsidized contraceptive pills including Nordette, Tri-Regol, Gynera and others. 14 The Personal Choice programme advertises its message on radio and television, as well as in newspapers. To gauge the effectiveness of these messages women were asked whether they had ever heard or read any family planning message in the media and whether they had ever heard or read a Personal Choice message. More than 90 percent of women had heard or read a message of any kind and more than 80 percent a Personal Choice message (Table 7.1), demonstrating that these messages were effectively reaching a high proportion of their target audience. There was little difference according to respondents' characteristics, except women under the age of 20, women in the "low" socio economic group and those not currently using contraception were slightly less likely to have heard or read these messages. More than 75 percent of women had heard or read a Personal Choice message in all parishes except St. Mary, where much less, only 57 percent of women, had ever heard or read a message. Women using pills were asked the brand they used, which were then classified by type of programme. Table 7.2 presents the distribution of the different brands of pills by residence of the respondent. The Personal Choice programme was the largest source of oral contraceptives. Broken down by residence, the commercial sector was most heavily patronized in the Kingston Metropolitan Area, and while other urban residents favoured the Personal Choice programme; rural residents used the public sector Personal Choice programmes to approximately the same extent. Some 45 percent 14 Brand names are stated to classify use according to programme and do not imply endorsement by the National Family Planning Board or the Centers For Disease Control and Prevention. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 51 CHAPTER 7 - Hormonal Contraceptive Use of pill users reported using brands of the Personal Choice programme, with 32 percent using Perle 15 and 13 percent using Minigynon. The highest use of Perle was in "other urban" areas and rural areas (32 - 33 percent); use was lower in the Kingston Metropolitan Area (29 percent). For Minigynon, on the other hand, highest use was in "other urban" areas (22 percent); use in the Kingston Metropolitan Area (14 percent) and rural areas (10 percent) was lower. In the public sector programme, use of Lo-Femenal was lowest in the Kingston Metropolitan Area and highest in rural areas (23 percent). Use of Ovral, on the other hand, showed no particular pattern. Two of the three brands identified in the commercial sector programme, Nordette and Tri- Regal as well as the "other" group, had their highest percentage of use in the Kingston Metropolitan Area and lowest use in rural areas. Use of the different brands of pills was also examined according to the socio economic index (Table 7.3). As the socio economic level rose, pill users used the commercial sector to a greater extent and the public sector to a lesser extent. Within the Personal Choice programme, Perle was used to a slightly greater extent by users in the lowest socio economic group and Minigynon used more by those in the highest group. To measure respondents' perception of the effectiveness of the pill, women were asked: "If a woman takes the pill correctly, how sure can she be that she will not become pregnant? " The findings are presented in Table 7.4 by health region, education and pill use. Overall, 40 percent indicated they were "completely sure", 24 percent were "almost sure", 13 percent believed there was "some risk of pregnancy", while 8 percent felt it was "not sure at all" that a woman would not get pregnant while taking the pill. Sixteen percent of women said they "did not know". Looking at the responses by health region, by combining the "almost sure" and "completely sure", responses, there was little difference between them, as between 64 and 66 percent of respondents were almost or completely sure, except for Health Region 2, where the percentage was slightly lower at 60 percent. Except for the youngest and oldest age groups, who are, in fact, the women who used the pill the least, more than 70 percent of women were "almost sure" or "completely sure" that the pill would prevent pregnancy. This is borne out in the by looking at this question by ever use and current use of the pill, as 78 percent of ever users and 87 percent of current users were "almost sure" or "completely sure" that the pill would prevent pregnancy if correctly taken. 15 It should be noted that many women refer to other brands as Perle. Accordingly, the percentages here could be overstated. 52 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY Chapter 7 - Hormonal Contraceptive Use A second question about the pill was "How safe for a woman's health is the pill"? The findings in Table 7.5 show that overall 36 percent of women reported that they consider the pill to be safe, and 30 percent considered it to be "not safe"; some 14 percent said that it "depends on the woman" and 20 percent said that they "did not know". The youngest age group (15-19), who along with the 45 to 49-year-old group used the pill the least, also had the lowest percentage of those who considered the pill completely safe. Ever and current pill users, with greater experience, had more confidence in its safety. There was almost no variation by education. 7.B INJECTION USE Table 7.6 similarly presents women's perception of the safety of injectables. The question and possible responses were the same as for the pill. Twenty-five percent considered injectable contraceptives safe, while one-fourth (26 percent) did not know if they were safe or not. Of those who had ever used injectables, 41 percent responded "completely safe", and 64 percent of currently users consider them completely safe. Again, perception of safety varies with age: the younger the age, the lower the perception of safety, with minor variation. There was little variation by education. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 53 CHAPTER 7 - Hormonal Contraceptive Use 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 54 Chapter 8 - Condom Use CHAPTER 8 CONDOM USE 8.A CONDOM USE Respondents who have had sexual relations were asked a series of questions about condom use. Two of these were "Have you ever asked a partner to use a condom?" and "Has a partner ever suggested to you that he wear a condom?" The results are presented in Table 8.1. More women had asked a partner to use a condom than their partners had suggested to them that he use a condom. Slightly over 50 percent of women had asked a partner to use a condom compared with about one-third whose partner had asked her to let him use a condom. The likelihood of women to ask a partner to use a condom varies with their age, as younger women are more likely to ask. More than 58 percent of 15-29 year olds have asked a partner to use a condom; this is true of only 23 percent of 45-49 year olds. The necessity to ask can be attributed to a number of factors; for example, women in relatively stable relationships may have less fear of contracting human immunodeficiency virus (HIV) or other STDs. As indicated previously, older women are more likely to be in a more stable relationship, and younger people may be more likely to speak openly about such topics. The above hypothesis is borne out by the findings based on relationship status. Women in marital unions were the least likely to have asked a partner to use a condom (40 percent), compared with those in common-law unions and visiting relationships (50 and 62 percent, respectively). The percentage of women with boyfriends who have ever asked a partner to use a condom is similar (60 percent). The percentages above relate to all respondents, whether or not they ever used a condom. The lower part of the table shows that 69-70 percent of those women who ever used a condom and 81 percent who are currently using have ever made such a request of a partner. Women with more education and in higher socio economic groups are also more likely to make such request of their partners. In the case of partners suggesting that they use a condom, the pattern is similar, including ever and current use of condoms. A male partner was more likely to suggest using a condom if the woman was younger, currently in a relationship with a boyfriend and had ever used condoms. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 55 Chapter 8 - Condom Use One aspect of condom use that was explored was negative reactions of partners to condom use. The following question was asked: "Has any of the following ever happened to you because you asked a partner to wear a condom ? 1 He refused to wear a condom. 2 He refused to have sex with you. 3 He threatened you. 4 He threatened never to go with you again. 5 He forced you to have sex without a condom. Another question asked was Has any of the following ever happened to you because a partner wanted to wear a condom? 1 You refused to let him wear a condom 2 You refused to have sex with him. 3 You threatened never to go with him again. The findings from these questions are presented in Tables 8.2 and 8.3. The strongest reaction to a woman asking her partner to use a condom was his refusal to do so; one quarter of the women reported that this was so. Smaller percentages of women indicated that they were forced to have sex without a condom (7 percent), or the partner refused to have sex with them (5 percent). Approximately one percent reported that the partner threatened them or threatened not to go out with them again. The reaction of women to the suggestion coming from their partners is not as strong as the reaction of the males. Nine percent reported that the women refused to let them wear the condom, six percent refused to have sex with the partner who made the suggestion, and 2 percent threatened never to go out with him again. The correlation between these responses and education and residence was not strong. 8.B REASONS FOR CONDOM USE All respondents were asked to identify whether or not they were concurrently using two contraceptive methods. If the answer was "yes", then the more effective method was defined as the primary method and the less effective method was defined as the secondary method.16 Table 8.4 looks at condom use according to this definition. Of those women who reported they use condoms 16 See Notes 11 and 12 in Chapter 6. 56 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY Chapter 8 - Condom Use as a primary method, over 90 percent had used a condom at their last sexual intercourse; of those who had used it as a secondary method, 67 percent had used a condom at their last sexual intercourse. Among those who used condoms as a primary method, the pattern of use did not vary by socio economic characteristics. For women who used condoms as a secondary method, use at last sexual intercourse was lower among those in the 25-34 year old age group and in Regions 2 and 4, as well as in rural areas in general, although the sample sizes do not allow any conclusions to be drawn. Education did not appear to have an impact on levels of use. The reasons for condom use are examined in Table 8.5. Twenty-three percent of women indicated that they used condoms only to prevent pregnancy, 25 percent only to prevent STDs, and 50 percent used condoms for both reasons. This contrasts with the 1993 survey when 29 percent reported that they used condoms to prevent pregnancy, 6 percent to prevent STDs and 65 percent to prevent both (data not shown). How is this translated into frequency of condom use? The middle panel of Table 8.5 shows that approximately one-half of condom-using respondents reported that with a steady partner they always used a condom. A further one-third reported using a condom most of the time, and 17 percent report using it some of the time. It is important to note, however, that in reporting condom use with a non- steady partner (lower panel of Table 8.5), more than three-fourths of women who rely on condoms say that they do not have a non-steady partner. Of those few who acknowledge having a non-steady partner, there is roughly an even split between those who always use and those who never use a condom. 8.C EFFECTIVENESS OF CONDOM USE How do respondents perceive the effectiveness of condoms to prevent pregnancy and STDs? This was examined by two questions: (a) If a couple uses a condom correctly, how sure can the woman be that she will not become pregnant? and (b)Ifa couple uses a condom correctly, how sure can the woman be that she will not get a sexually transmitted disease like gonorrhea, syphilis or AIDS?" Possible responses were completely sure, almost sure, some risk of pregnancy / of getting STD, not sure at all and don't know. The answers to these two questions are given in Tables 8.6 and 8.7 Approximately one-third of respondents felt that condoms were a completely sure way of preventing pregnancy, one-quarter were almost sure and one-fifth believed that there was some risk. The percentages are similar for respondents' perception of condoms' effectiveness to' prevent STDs. There was little difference in the degree of certainty regarding the prevention of pregnancy and STDs 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 57 Chapter 8 - Condom Use according to socio economic characteristics of respondents, except slightly more women in the lowest education category did not know if condoms were effective or not. Also, there was some variation by parish. There were also marked similarities between the results of the two tables for ever or current users of condoms compared to never and non current users of condoms. The percentage of respondents who were completely sure of the efficacy of condoms was much lower in both of the latter groups, meaning there is scope for increased education on the value of condoms. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 58 Chapter 9 -Sterilization Use and Demand CHAPTER 9 STERILIZATION - USE AND DEMAND 9.A USE OF STERILIZATION The profiles of in union women who have and have not been sterilized are compared in Table 9.1. Women who have been sterilized tend to be older than the non-sterilized, to have over two children more, on average, than the non-sterilized (mean of 4.1 compared with 1.9), to be in a more stable relationship, to be less educated and to attend church more frequently. Socio economic index does not appear to differ. The above data on mean number of live births indicate that, in Jamaica as in other countries, women who become sterilized tend to be self-selected for their higher parity; that is more than half of all sterilized women have four or more children, and half of all pregnancies among women with four or more live births were unwanted (see Table 3.14). The lower educational attainment of sterilized women is due in part to high parity being negatively correlated with education. These data have not changed substantially since 1993. Table 9.2 examines, for those women in a union who have been sterilized, when during their reproductive life the operation took place. In 1997, some 64 percent of sterilized women had the procedure between ages 25 and 34, with a mean age of 30.7. Fifty-seven percent of sterilized women already had 4 or more live births, with a mean of 4.1. The data for 1993 and 1989 show that the mean number of live births at sterilization has been falling (from 4.7 in 1989 to 4.3 in 1993), although there was little change in the mean age at sterilization. The mean number of children ever born to sterilized and non-sterilized women are compared by age group in Table 9.3. Comparisons with 1993 are also shown. In each age group, the sterilized women have at least one child or more than the non-sterilized, with the difference narrowing as age increases. This is the same pattern observed for 1993. This, again, is an indication that women who are sterilized in Jamaica tend to be self-selected for their higher fertility. 9.B SATISFACTION WITH STERILIZATION In 1993, thirteen percent of sterilized women stated that, for a variety of reasons, they were not satisfied with having had the operation; in 1997 this proportion had fallen to 7 percent (Table 9.4). In 1997, as well as in 1993, dissatisfaction was highest for women who were less than 30 years at the time of sterilization. Also, the value of counselling prior to the operation can be seen since, in 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 59 Chapter 9 - Sterilization Use and Demand 1993 and 1997, women who were not counselled before the operation were much more likely to be dissatisfied than women who had been counselled. Not shown in a table is that in 1997, among those not satisfied with the operation, almost half had side effects or complications resulting from the operations itself, while less than one-third of unsatisfied women, or about 2 percent of sterilized women overall, stated that they regretted having been sterilized because they wanted more children. 9.C DEMAND FOR STERILIZATION Table 9.5 looks at the potential demand for sterilization among women who are fecund (that is, are capable of getting pregnant) and who do not want any more children. In 1993, about one-third of women in this group (35 percent) stated that they were interested in having the operation. This interest was higher for women who were in a union, who had 4 or more children, and who were 30- 34 years of age. In 1997, the overall percentage fell to 23 percent. The percentage increased by age up to age group 30-34 and fell thereafter. As in 1993, interest also increased with the number of live births. A higher percentage of among women in the "low" socio economic group are interested, no doubt because they have higher parity than in the "high' socio economic group. 9.D REASONS FOR NON-STERILIZATION Non-sterilized women who did not want more children, but were not interested in sterilization, were asked the reason why they were not interested (Table 9.6). Twenty-six percent indicated that they were afraid of the operation, while 16 percent of women said they might want children in the future. Another 15 percent of women identified fear of the method and possible side effects, 10 percent said they were too young and 8 percent reported that they were not sexually active. Certainly, those who expressed fear of the operation, fear of method and side effects, those who are "thinking about it", "don't believe in it" and who indicated lack of information could presumably be the target of educational efforts to inform them of the benefits and safety of female sterilization. There was no pattern of differences for these reasons according to years of education. Those women who did not want more children, but were interested in sterilization and who were not yet sterilized, were asked why they had not been sterilized. Table 9.7 presents this data by years of education. Some 21 percent of women in this group reported that they were "thinking about it"; a further 16 percent cited "lack of information", 11 percent were "currently pregnant" and a further 11 percent indicated "fear of the operation and its side effects". As one out of four women cited lack of information or fear of the operation, certainly an appropriate information programme could be aimed at those women. There was little difference according to education for these major reasons. Of the lesser reasons for not being sterilized, the only appreciable difference reported by education was "lack of money", which was reported to a much lesser extent by those with 10 or more years of education, since better educated respondents were also in higher economic groups. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 60 Chapter 9 -Sterilization Use and Demand As shown in Table 9.8, of those women who have indicated that they still wanted children, 25 percent would be interested in becoming sterilized after having all the children they want. Age was not a determinant. As the number of respondents' live births increased, the percentage interested in sterilization increased up to three births and then fell off. There was no pattern by number of additional children wanted or by relationship status. Interest was inversely related to church attendance. For those 1,817 women who indicated that they would not be interested in sterilization even after they have had all the children they want, Table 9.9 presents their reasons for not being interested. The most frequent reasons were: "fear of the operation", followed by "may want to have more children in the future", though the percentage stating this latter reason fell with age. Also, "Fear of method and side effects" was stated by 16 percent of these respondents, and 12 percent said they were "too young". Presumably, education efforts could convince a proportion of this large group of women of the safety of tubal ligation. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 61 Chapter 9 - Sterilization Use and Demand 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 62 Chapter 10 - Non-Use of Contraceptives CHAPTER 10 NON-USE OF CONTRACEPTIVES 10.A DISCONTINUATION AND FAILURE RATES As mentioned previously, the survey data have shown that, with increasing age, the tendency has been to switch from shorter term methods, such as the condom and the pill, to more long term methods, such as injectables and finally tubal ligation. Accordingly, discontinuation rates (calculated using life table methodology), or the percentage of users of the pill, injectables and condoms who discontinued use after selected periods of time are presented in Table 10.1. The periods used are discontinuation: after 12 months; after 24 months and after 36 months. The percentage of women who discontinued condom use at the end of each period were higher than for the pill or the injection (which are about equal). After 12 months, the percentage of users who discontinued using the condom was 42 percent compared with 32 percent for the pill and 31 percent for injectables; after 24 months, the comparative rates were 59, 48 and 50 percent, respectively, while after 36 months, the rates were 67, 61 and 58 percent, respectively. The percentages were fairly similar according to health region. Contraceptive failure rates (as was the case for discontinuation rates) were based on information from a five-year contraceptive calendar. Whenever a woman reported that she became pregnant while using a contraceptive method it is considered to be a contraceptive failure, regardless of whether the pregnancy resulted from a failure of the method or improper use of the method. Table 10.2 shows failure rates, based on life table calculations, after 12, 24, and 36 months for pills, injectables, and condoms, according to health region. Twelve-month failure rates for Jamaica as a whole were found to be about 4 percent for pills, 0.3 percent for injectables, and 5 percent for condoms. These failure rates are not out of the ranges typically found for each of the three methods examined (Hatcher et al., 1998). Somewhat surprisingly, the failure rates for each of the methods appear to be just as high in the second and third years of use as in the first year. There do not appear to be any consistent variations in failure according to health region. 10.B REASONS FOR NOT USING A CONTRACEPTIVE METHOD The reasons why women and men say they are not currently using contraception are examined in the next series of tables. Eighty-six percent of female non-users gave reasons for non-use related to pregnancy, subfecundity or sexual activity, which cannot be changed through education (Table 10.3). Most women in this group said they were not sexually active (58 percent of total), while 11 percent reported they were currently pregnant, a further 8 percent indicated a desire to get pregnant and 10 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 63 Chapter 10 - Non-Use of Contraceptives percent were sub-fecund or post-partum. The remaining 14 percent of non-using women gave other reasons, including "don't like" contraception, being "against" contraception and having concerns about side effects. Presumably some of the women in this group could be persuaded to use contraception through educational efforts. These data are similar to the corresponding data from the 1993 JCPS. Reasons for non-use are presented according to several social and demographic variables factors in Tables 10.4 and 10.5. The following points can be made: (1) Reasons for non-use by women vary according to relationship status (Tables 10.4). Although the major reason for non-use by women who were in a marital union was sub fecundity and for those in a consensual union it was current pregnancy, the primary reason for women in a less stable or in no relationship was absence of sexual activity. (2) Reasons for non-use by last contraceptive method used showed that those women who never used a method were most likely (80 percent) to report they were not using contraception because they were not sexually active (Table 10.5). Those women who last used a hormonal method, the pill or injection, were more likely than others to state reasons related to side effects and health concerns. Interestingly, the highest percentage of women saying they are not using because they are currently pregnant (28 percent) were those whose last method was withdrawal, which may be related to this method's relatively high failure rate. Respondents using contraception were asked if they would prefer a method other than the one they were currently using. As shown in Table 10.6, 87 percent of women currently using a contraceptive method indicated satisfaction with their current method. Of the 13 percent of users who preferred to use another method, almost all preferred a more effective method. For example, of the 21 percent of IUD users who preferred another method, 15 percent indicated tubal ligation as the preferred method. Also, 12 percent of condom users preferred the pill or injection and 4 percent of pill users wanted to switch to injections. 10.C NEED FOR FAMILY PLANNING SERVICES The survey data indicate that certain segments of the population have greater need of family planning services than others. A woman was characterized as "in need of services" if she was sexually active, not currently pregnant, stated that she did not desire to become pregnant, and was not using any method of contraception for reasons not related to subfecundity. According to this definition, 15 percent of the women were estimated to have an unmet need for contraception, compared with a slightly lower proportion, 14 percent, in 1993 (Tables 10.7 and 10.8). 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 64 Chapter 10 - Non-Use of Contraceptives The level of unmet need varied according to the variables included in the study. The following summary points can be made: (1) Women with no steady partner, who are largely young women, had the highest level of unmet need (Table 10.7), and their level of unmet need had increased since 1993 (p=0.05). Married women had a higher level of unmet need compared to 1993, when they had the lowest percentage of unmet need (p=0.06). Almost one in five 15-19 year old women had an unmet need for family planning services. (2) Unmet need was highest in the Kingston Metropolitan Area and Health Region 2 and lowest in Health Region 3 (Table 10.8). To summarize, the need for family planning services among women was about 15 percent for all sub groups (about 13% for women in union), but it was higher for those under 20 years of age, for those with a boyfriend or no current steady partner, for women who attended religious services regularly, and for those whose level of education was highest. It was also relatively high in St. Andrew, St. Thomas, Portland, St. Ann and Manchester. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 65 Chapter 10 - Non-Use of Contraceptives 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 66 Chapter 11 - Young Adults CHAPTER 11 YOUNG ADULTS 11.A GENERAL The 1997 Reproductive Health Survey continues the study of young adult men and women aged 15- 24 years, because concern about the high level of unintended adolescent childbearing has indicated a special analysis of the problem. A separate report, specific to young adults, will complete the series of final reports on the 1997 survey. Accordingly, this chapter provides a summary of the available data. 11.B SOCIO DEMOGRAPHIC CHARACTERISTICS The age distribution of the young adult population, male and female, sampled in the JRHS, 1993 JCPS and 1987 YARHS is shown in Table 11.1. The data were similar for the three surveys. Another variable studied is employment status, which is presented in Table 11.2. Among young women, the highest percentage were students (35 percent), the next highest were working (25 percent), a further 22 percent were keeping house, and a lower percentage was unemployed (18 percent). Among young men half were working, and only 29 percent were students. Within every age group, men were more likely than women to report that they were currently working. Approximately four of five men 20-24 years of age reported they were working. The proportions of men and women who were unemployed was highest among those aged 18-19. Women are much more likely than men to report that they were keeping house. As would be expected, the proportions in school decline with increasing age among both men and women. The relationship status of young adults is shown in Table 11.3. Approximately one-third of both genders had no steady partner and only a small percent were married (2 percent of women and 0.5 percent of men). One-third of both women and men had visiting partners, which was the most common relationship status in this age group. 11.C EXPOSURE TO FAMILY LIFE EDUCATION Courses for young adults in family life and sex education are offered in schools and at other venues outside of schools. Table 11.4 looks at young adults who took a course in family life or sex education by where the course was taken and by age group. Comparisons are made with 1993. The percentage of young adults who have taken a course increased since 1993 from 80 to 86 percent for women and from 68 to 76 percent for men. As may be observed, in both years, the percentage of 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 67 Chapter 11 - Young Adults those who took a course was higher for women than for men. Courses in school were the most common for both young women and young men. The topics covered differed by gender (Table 11.5). For example, the menstrual cycle was almost universally covered for women in both years, but a lower percentage of men, 85 percent in 1997 and 79 percent in 1993, had this topic covered in their course. Men were taught about condoms and AIDS to a slightly greater extent than women, perhaps because they were considered to be at greater risk of contracting AIDS. Teaching about AIDS increased for both sexes since 1993. About two- thirds of young men and women were taught about counselling services available for adolescents, while less than half were taught about clinic services and only one-third about contraceptive distribution. The percentages of those taught about service availability were low when compared to the percentages taught about the more theoretical aspects of reproductive health. Also, since the possible responses to these questions were read to respondents, the possibility that they would not recall what topics they were taught was minimized. Steps should be taken to encourage teaching of the availability of clinic services and contraceptive distribution. Without being specific as to the exact place, Table 11.6 shows the proportion of young adult males and females who knew where to go for information on sex or contraceptives or on treatment of STDs. Eighty-eight percent of young women and 83 percent of young men indicated that they knew where to go for information on sex or contraception. Both women and men in the youngest age group were least likely to know where to go. Those who took a family life or sex education course or were in the higher socio economic category were more likely to know than others. The pattern was similar for those who knew where to go for treatment of STDs, but overall knowledge was higher and the variations are less marked. 11.D EXPOSURE TO SEXUAL ACTIVITY Table 11.7 shows the majority of both women and men aged 15-24 reported, at the time of the survey, that they have had sexual intercourse (70 and 85 percent, respectively). As expected, the proportion increases with age; 38 percent of young women and 64 percent of young men in the 15-17 year old age group are sexually experienced and by age 25 nearly all women and men are sexually experienced. This pattern was similar to that seen in 1993 and 1987 (data not shown). Women reported a decline in sexual experience since 1993, although this decline was not quite significant statistically (p=0.06). This decline for young women was only among adolescents 15-19 years of age (p=0.06). There was no change for 20-24 year old women or for men at any age. Table 11.8 shows that the mean age at first intercourse reported for young women of 15.9 years was approximately 2 years older than that reported by men in both 1997 and 1993. Although the mean 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 68 Chapter 11 - Young Adults age at first sexual experience did not vary by residence among women, more men residing in urban areas reported being sexually experienced at an early age than those in rural areas. For women, the mean age at first intercourse rose with educational attainment and socio economic status. Also, the mean was generally higher with more frequent church attendance. Virtually all young women and men reported that their first sexual experience occurred outside of a consensual union or legal marriage (Table 11.9). The majority of young women described their first partner as a boyfriend; the proportion increasing as age at first intercourse increased up to age 18-19. In contrast, fewer than half of young men described their first partner as a girlfriend, and most of the remainder described her as "a friend". Among men, an older age at first intercourse tended to be associated with a girlfriend relationship; while first intercourse with a friend showed an inverse relationship until age 20. 11.E CONTRACEPTIVE USE AT FIRST INTERCOURSE Patterns of contraceptive use at first sexual experience were different for men and women. Table 11.10 shows that 56 percent of young women reported use of contraception at first intercourse and this proportion was significantly higher than the 43 percent who used contraception at first intercourse in 1993. As might be expected, similar to 1993, those who were older at first intercourse were generally more likely to use contraception. Other characteristics associated with a greater likelihood of contraceptive use at first intercourse included a more stable relationship, higher educational attainment and higher socio economic status. Thirty-one percent of young men reported in 1997 that they used contraceptives at their first sexual intercourse. This is 9 percentage points (44 percent) more than was reported in 1993, which was in itself half again as great as the proportion of young men who so reported in 1987 (data for 1987 not shown). Nonetheless, 31 percent is well below the level reported by women, in part attributable to the younger age of men at first intercourse, as the likelihood of contraceptive use generally increased with age at first intercourse. Variation according to other characteristics of men was similar to that of the women, but at a lower level. Variation by parish was marked; for women, the proportion who used contraception at first intercourse ranged from 68 percent in Portland to 43 percent in St. Thomas; for men, the range was from 48 percent in St. James to 8 percent in Kingston; however, parish results should be treated with caution due to the small sample sizes. 11.F SOURCE OF CONDOMS The source of condoms is the only source of contraception examined, as 88 percent of young women and 94 percent of young men who used any method at first intercourse used a condom (data not shown). Among young women, the primary source of condoms used at first intercourse was the 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 69 Chapter 11 - Young Adults pharmacy, followed by the supermarket or shop; government clinics were in third position (Table 11.11). One-third of women, however, reported that they did not know where the condoms were obtained; no doubt because the male partner obtained them. Young men identified the supermarket or shop as their primary source of condoms, followed by the pharmacy. An important source for young men was other sources, mostly friends (29 percent in 1997 and 41 percent in 1993). Very few men reported that they did not know where the condom was obtained. 11.G REASONS FOR NOT USING CONTRACEPTION AT FIRST INTERCOURSE Table 11.12 presents the reasons for not having used contraception at first intercourse. This table shows that nearly half of young women and approximately one-third of men who did not use contraception at first intercourse in both 1997 and 1993 reported the reason is that they did not expect to have sexual intercourse. A second reason given (13 percent and 21 percent of young women in 1997 and 1993, respectively, and one-third of young men in both years) is that they did not have knowledge of contraception at that time. The next most quoted reason given was that they could not get the method at that time. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 70 REFERENCES Contraceptive Prevalence Survey, Jamaica - 1983 by Dorien Powell. National Family Planning Board; August 1984. Contraceptive Prevalence Survey, Jamaica -1989 by Carmen McFarlane and Charles Warren. National Family Planning Board; December 1989. Contraceptive Prevalence Survey, Jamaica -1993, Volumes I-V, By Carmen McFarlane, Jay S. Friedman, Leo Morris and Howard I. Goldberg. National Family Planning Board; October 1994. RA Hatcher, J Trussell, et al. 1998. Contraceptive Technology, Seventeenth Revised Edition, Ardent Media, New York. Demographic Statistics - 1995. Statistical Institute of Jamaica; 1996. Demographic Statistics - 1996. Statistical Institute of Jamaica; 1997. Jamaica Fertility Survey 1975-76, Country Report, Vol. II. Dept. of Statistics, Kingston, Jamaica; 1979. Robey, B., Rutstein, S.O., Morris L., and Blackburn, R. The Reproductive Revolution: New Survey Findings. Population Reports, Series M, No. 11. Baltimore, Johns Hopkins University, Population Information Program, December 1992. A Statement of National Population Policy. Prepared by the Population Policy Task Force, Ministry of Health, August 1981; revised by Population Policy Coordinating Committee, National Planning Agency, 1998. Young Adult Reproductive Health Survey, Jamaica -1987, National Family Planning Board in collaboration with Dorien Powell and Jean Jackson with technical assistance from Statistical Institute of Jamaica and Centres for Disease Control; March 1988. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 71 72 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY APPENDIX I SAMPLING ERROR ESTIMATES The estimates for a sample survey are affected by two types of errors: non-sampling error and sampling error. Non-sampling error is the result of mistakes made in carrying out data collection and data processing, including the failure to locate and interview the right household, errors in the way questions are asked or understood, and data entry errors. Although intensive quality-control efforts were made during the implementation of the 1997 JRHS to minimize this type of error, non- sampling errors are impossible to avoid altogether and difficult to evaluate statistically. Sampling error is a measure of the variability between an estimate and the true value of the population parameter intended to be estimated, which can be attributed to the fact that a sample rather than a complete enumeration was used to produce it. In other words, sampling error is the difference between the expected value for any variable measured in a survey and the value estimated by the survey. This sample is only one of the many probability samples that could have been selected from the female population aged 15-49 and the male population aged 15-24 using the same sample design and projected sample size. Each of these samples would have yielded slightly different results from the actual sample selected. Because the statistics presented here are based on a sample, they may differ by chance variations from the statistics that would result if all women 15-49 years of age and all men aged 15- 24 in Jamaica would have been interviewed. Sampling error is usually measured in terms of the variance and standard error (square root of the variance) for a particular statistic (mean, proportion, Or ratio). The standard error (SE) can be used to calculate confidence intervals (CI) of the estimates within which we can say with a given level of certainty that the true value of population parameter lies. For example, for any given statistic calculated from the survey sample, there is a 95 percent probability that the true value of that statistic will lie within a range of plus or minus two SE of the survey estimate. The chances are about 68 out of 100 (about two out of three) that a sample estimate would fall within one standard error of a statistic based on a complete count of the population. The estimated sampling errors for 95% confidence intervals (1.96 x SE) for selected proportions and sample sizes are shown in Table 1. The estimates in Table 1 can be used to estimate 95% confidence intervals for the estimated proportions shown for each sample size. The sampling error estimates include an average design effect of 1.6, needed because the JRHS did not employ a 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY simple random sample but included clusters of elements in the second stage of the sample selection. The selection of clusters is generally characterized by some homogeneity that tends to increase the variance of the sample. Thus, the variance in the sample for the JRHS is greater than a simple random sample would be due to the effect of clustering. The design effect represents the ratio of the two variance estimates: the variance of the complex design using clusters, divided by the variance of a simple random sample using the same sample size (Kish L., 1967). For more details regarding design effects for specific reproductive health variables, the reader is referred to the Le and Verma report, which studied demographic and health surveys in 48 countries (Le TN and Verma JK, 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY 1997). The pattern of variation of design effects is shown to be consistent across countries and variables. Variation among surveys is high but less so among variables. Urban -rural and regional differentials in design effects are small, which can be attributed to the fact that similar sample designs and cluster sizes were used across domains within each country. At the country level, the overall design effect, averaged over all variables and countries, is about 1.5 (we used 1.6 in Table A. 1 to be slightly more conservative). To obtain the 95% CI for proportions or sample sizes not shown in the table, one may interpolate. For example, for a sample size of 200 and a point estimate of 25% (midway between 0.20/0.80 and 0.30/0.70), the 95% CI would be plus or minus 7.5%; for a sample size of 300 (midway between 200 and 400) and an estimate of 20%, the 95% CI would be plus or minus 6.0%. Differences between estimates discussed in this report were found to be statistically significant at the five percent level using a two-tailed normal deviate test (p=0.05). This means that in repeated samples of the same type and size, a difference as large as the one observed would occur in only 5% of samples if there were, in fact, no differences between the proportion in the population. In this text, terms such as "greater," "less," "increase," or "decrease" indicate that the observed differences were statistically significant at the 0.05 level using a two-tailed deviate test. Statements using the phrase "the data suggest" indicate that the difference was significant at the 0.10 level but not the 0.05 level. Lack of comment in the text about any two statistics does not mean that the difference was tested and not found to be significant. The relative standard error of a statistic (also called "coefficient of variation") is the ratio of the standard error (SE) for that statistic to the value of the statistic. It is usually expressed as a percent of the estimate. Estimates with a relative standard error of 30% or more are generally viewed as unreliable by themselves, but they may be combined with other estimates to make comparisons of greater precision. For example, an estimate of 20% based on a sample size of only 50 observations yields a SE of 7% (one half the 95% confidence interval shown in Table A.l). The relative standard error would be 35% (the ratio of the SE of 7% to the estimate of 20%), too large for the estimate to be reliable. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY APPENDIX II COMMENTS MADE BY DISCUSSANTS AT THE NATIONAL DISSEMINATION SEMINAR 1997 REPRODUCTIVE HEALTH SURVEY August 25,1998 1. Fertility Discussant: Dr. Eva Fuller 1. Total Fertility Rate (TFR) of 2.8 is disappointing, disconcerting. 2. There needs to be some work done, an example of which is that being done in Japan, to get TFR down to 1.4. Observations of concern 1. Increase in age-specific fertility rate of 15-19 year olds. 2. One-third of teenagers surveyed had a child by age 20 years. 3. Non-use of contraceptives at first sex by teenagers. 4. High prevalence of short term methods. 5. Short duration of exclusive breastfeeding - a worrying finding. Recommendations 1. Jamaica has not in the past focussed on adolescent groups. This should be the new policy direction. The Ministry of Health is now working with other agencies to structure the reproductive health programme. 2. The age of admission of children at the Bustamante Children's Hospital should be extended to age 15 years. 3. There is the need to improve the Health Seeking Behaviour Programme. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY APPENDIX II NATIONAL DISSEMINATION SEMINAR 4. There should be a return to "Two is better than too many" campaign of the 1980's, with special focus on young adults. 5. The reproductive health policy should include provision for the emergency marketing of contraceptives (ECP) to this age group. 6. There should be consistent promotion of condom use. 7. Questions on family life education (FLE) should be included in the National Assessment Paper (NAP). Future examination 1. Abortion rate should be studied in order to assess its impact on fertility. 2. Further research should be carried out on: a) the indicator - mean number of children desired. b) the gender of older children. c) timing of last birth in relation to number of children desired. 3. The findings of the survey should be interpreted so that the average lay person can understand and apply them. 2. Other Reproductive Health Issues Discussant: Dr. Diane Ashley 1. The survey cannot measure quantitative issues and many questions arise from quantitative data. 2. The findings should be compared with trends observed in other studies. (The parish data should be reviewed). 3. No multivariate analysis has been done on the findings or tests of statistical significance. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY APPENDIX II NATIONAL DISSEMINATION SEMINAR 4. The policy in place is to reduce numbers seen for routine prenatal care at government hospitals. 5. Rural / urban differences in prenatal care are due to access. Rural area has less access to services especially in the private sector. Income and educational levels are among the factors which influence where people go for services. 6. Age / parity has been used as the criteria of risk in this study as these are two most important factors that influence maternal mortality. Even with just two variables, the findings show a similar range for proportion of high-risk pregnancies. (???). 7. Adequacy of care measured in numbers is inadequate but gives some idea of level of care. 8. With respect to the inadequate care in rural areas especially in the North-East and Southern regions, the findings show that they have the highest maternal mortality, highest rate of Nana deliveries and the lowest rate of doctor intervention. 9. In Trelawny, the findings are similar to those in the North-East health region rather than in the West, the health region in which it falls. Follow-up qualitative work is required. 10. St. Catherine was found to have the largest proportion of high-risk pregnancies with adequate prenatal care. A special programme is in place in St. Catherine. 11. Differences in prenatal visits are similar to those observed in other studies. These should be analyzed by economic status, union status, age and educational level. In the analysis, the following should be observed: a). Women in stable unions with previous history of miscarriage or abortion who are most likely to start prenatal care early. b). Late attendees who are likely to be among self-employed women with no one to continue economic activity; multiparous women with previous uncomplicated prenatal care and delivery. 12. With respect to the findings on blood pressure, variations between parishes have been observed. With respect to diastolic hypertension, the difference in prevalence is 11 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY APPENDIX II NATIONAL DISSEMINATION SEMINAR percent while there was a 14 percent differential between health regions. These differences may be due to different definitions applied in the different areas. Also, the frequency of measurement taken during pregnancy can account for the three percent difference between the report during pregnancy and that outside of pregnancy. 13. With respect to both pap smears and breast self-examination, a lot of work needs to be done in these programmes. 14. Data suggest (through analysis) access to care varies between regions, amount of care provided to those at high risk, coincides with areas already identified with high maternity mortality rate. 15. It would be instructive to identify if there is correlation between highest TFR and contraceptive prevalence rate. 16. Clients should be targeted in relation to access and quality of service. 17. With respect to educational services, the major difference between contraceptive use and other public health services should be observed. In this context, the factors affecting behaviour should be determined. 18. There is need to identify programmes which could lead to an upward shift in the mean age at first birth. 3. Contraceptive Knowledge, Use and Source Discussant: Dr. Olivia McDonald Dr. McDonald applied the findings of the survey in relation to the goal, objectives and strategies of the NFPB's five year strategic plan. Successes have been seen bit the impact is not tangible. Areas discussed were: current status of method mix, method source and improved efficacy of method use. The findings in the 1997 RHS were highlighted. These include, inter alia, changing attitudes towards reproduction and in particular, a preference for two children. Challenges for the programme were also mentioned. Steps suggested for follow-up are: 1. The programme should determine whether the goal should be an outcome or an output. 2. Consideration should be given to the expansion of Norplant. 1997 JAMAICA REPRODUCTIVE HEALTH SURVEY APPENDIX II NATIONAL DISSEMINATION SEMINAR 3. A programme matrix should be designed using a targeted approach. 4. Behaviour change communication by IEC: - selective advertising that promote specific methods to targeted groups; - needs as identified in the study of which two in particular was mentioned: reproductive physiology and ECP, particularly to extremes of the reproductive age group. 5. The programme should include a gender plan of action. Discussion 1. The differences in the socio-economic index and the educational criteria used in the findings should be defined. 2. It was proposed that Table 9.1 should be re-examined since there appears to be some inconsistency in the findings. 3. It was proposed that the TFR data should be disaggregated and that some analysis of sub- groups should be undertaken. 4. It was noted that other surveys had shown a consistently higher use of condom use as a secondary method than the earlier CPSs and the 1997 RHS 5. Specific targeting was proposed. 6. Gaps in the ECP for providers / clients were identified. 7. Size 48mm male condom and female condom proposed for intro

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