Reproductive Health Survey Jamaica 2008 Final Report National Family Planning Board

Publication date: 2010

i RReepprroodduuccttiivvee HHeeaalltthh SSuurrvveeyy JJaammaaiiccaa,, 22000088 FFiinnaall RReeppoorrtt PPrreeppaarreedd bbyy:: FFlloorriinnaa SSeerrbbaanneessccuu AAlliicciiaa RRuuiizz DDaanniieellllee SSuucchhddeevv National Family Planning Board Statistical Institute of Jamaica KINGSTON, JAMAICA United States Agency for International Development (USAID) KINGSTON, JAMAICA Division of Reproductive Health, Centers for Disease Control and Prevention (DRH/CDC) ATLANTA, GEORGIA, USA JJuunnee,, 22001100 ii This report is funded by the United States Agency for International Development (USAID) agreement with the Centers for Disease Control and Prevention, Division of Reproductive Health (CDC/DRH), USAID Contract No. HRN-C-00-97-0019-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID. Additional information about this report may be obtained from the CDC/DRH, Mailstop K-23, 4770 Buford Highway, NE, Atlanta, 30341–3724 USA. Fax (770) 488-6242; Tel (770) 488-6200 and the National Family Planning Board, 5 Sylvan Avenue, Kingston 5, Jamaica. Fax (876) 968-1626; Tel (876) 968-1631. Suggested citation: Serbanescu F, Ruiz A, Suchdev DB. 2010. Reproductive Health Survey Jamaica 2008: Final Report. Atlanta, GA (USA) and Kingston, Jamaica. Preface iii Preface The 2008 Reproductive Health Survey is the eighth in a series of periodic enquiries conducted by the National Family Planning Board. The scope of the survey, as in earlier studies, is designed to update measures of fertility and contraceptive use and other reproductive health issues among women aged 15-49 years and men 15-24 years. The findings will be beneficial as an evaluation and planning tool for the National Family Planning Programme. The field work for 2008 survey was completed in May 2009. The final report of the 2008 Reproductive Health Survey is presented in the three volumes: 1. Final Report 2. Young Adults Report 3. Regional Report The Board uses this opportunity to express gratitude to the Statistical Institute of Jamaica (STATIN), and the focal representative of the Centers for Disease Control and Prevention (CDC), Dr. Florina Serbanescu. We acknowledge the financial support of the United States Agency for International Development (USAID) and the United Nations Population Fund (UNFPA), as well as the technical support of the Division of Reproductive Health, CDC. Finally, no study of this sort could be possible without the co-operation of the citizens of Jamaica, who participated in the survey as respondents. It is with gratitude that we extend thanks and appreciation to them. Olivia McDonald Executive Director, NFPB June 2010 iv Institutional Participation Institutional Participation Agency Persons Involved Centers for Disease Control and Prevention, Division of Reproductive Health (CDC/DRH), Atlanta, USA Florina Serbanescu, Principal Investigator Alicia Ruiz, System Programmer (SAIC) Danielle Suchdev, Health Scientist Paul Stupp, Demographer Mary Goodwin, Epidemiologist Kanako Ishida, ORISE Fellow Leo Morris, Demographer (SAIC) Fernando Carlosama, System Programmer (SAIC) Jose Luis Carlosama, System Programmer (Mcking Corp.) Reina Turcios, Epidemiologist Susanna Binzen, Public Health Advisor USAID/Jamaica Jennifer Knight-Johnson, Project Management Specialist (Health) National Family Planning Board Olivia McDonald, Executive Director Kevin Bell, Policy Formulation, Evaluation and Monitoring Ellen Radlein, Policy Formulation, Monitoring and Evaluation Alphanso Williams, Statistician Sacha-Marie Hill, Research Officer Statistical Institute of Jamaica Douglas Forbes, Survey Director Annette McKenzie, General Director Natalee Simpson, Statistician, Project Manager Avery Gaynor, Senior Programmer Merville Anderson, Director, Field Services Division Day-Dawn Simon, Director, Research, Design and Evaluation Valerie Nam, Director, Division of Censuses Ministry of Health, Jamaica Peter Figueroa, Chief, Epidemiology and AIDS Members of the 2008 RHS Final Report editing and production team are acknowledged in bold. Executive Summary v Jamaica RHS 2008 Executive Summary Over the last two decades, there have been huge improvements in the area of reproductive health, adolescent health, and HIV prevention in Jamaica. Contraceptive prevalence has increased and the proportion of unplanned births has decreased. Adolescent fertility and risky sexual behaviors have declined. Maternal mortality and infant death have also declined, though they are still higher than in other places. Since 1975, the United States Agency for International Development (USAID) has invested resources to improve access to family planning and other reproductive health services in Jamaica. Through funds provided by USAID, several nationwide Contraceptive Prevalence Surveys (CPSs) and later Reproductive Health Surveys (RHSs) were conducted periodically in Jamaica, the most recent of them in 2008, all intended to assess and respond to the reproductive health needs of the population. Throughout these surveys, the USAID goal was to provide reliable information as a catalyst for evidence-based decision making and political action. The 2008 Jamaica RHS is a collection of important demographic and reproductive health indicators. These indicators are used to examine health trends and set targets for improvement, allocate resources, and monitor performance of reproductive health, HIV and adolescent programs. Several findings of the 2008 RHS are highlighted below: Introduction:  As the Jamaican government sets forth to improve the national family planning program, address the reproductive health of young adults, and develop national strategies to reduce interpersonal violence, the timing of the 2008 RHS, has been ideal.  Fieldwork for the Jamaica 2008-2009 RHS was completed in May 2009. The survey interviewed two independent nationwide samples of 8,259 women aged 15-49 and 2,775 men aged 15-24. vi Reproductive Health Survey, Jamaica 2008 Methodology:  The survey documents a wide array of key reproductive health outcomes and their determinants for women or reproductive age and young adult men. The detailed health content in the RHS allows for multiple correlates between health outcomes and knowledge, attitudes, sexual behaviors and preventive practices.  For the first time in Jamaica, the 2008 RHS collected key HIV/AIDS indicators and documented the level of domestic violence and gender norms among women and men.  Designing the sample to produce estimates for 14 regions of the country enables key stakeholders to better assess reproductive health at the sub-national level. The documentation of the wealth status (quintile) of the households provides a better understanding of the health disparities by socioeconomic status than in previous surveys.  This survey yielded a response rate of 97% for women and 94% for young men, one of the highest participation rates since the onset of these surveys. Marriage and Fertility:  Sixty-nine percent of women in the sample were legally married, in consensual unions, or in visiting partnership relations (14.8% were legally married, 22.5%, in common-law unions, and 31.2% in visiting partnerships). One in four (24.9%) women of reproductive age did not have a regular partner at the time of the interview, 3.6% had a boyfriend that they had sexual relations with, and 3.1% had a boyfriend without sexual relations.  The age at which women in Jamaica tend to start sexual activity has remained relatively steady since 1997. In 2008, the median age at first intercourse was 17.0 years old, compared to 17.0 in 2002 and 17.3 in 1997.  Jamaica’s fertility rates have been declining since the 1970s. The total fertility rate of 2.4 children per woman in Jamaica for 2006–2008 is the lowest ever documented in the country. Median age at first birth was 21.2 years, slightly older than 20.7 years documented in 2002.  Jamaican women initiate and complete childbearing at early ages, with the highest fertility levels reported among 20- to 24-year-old women, practically unchanged since 2002. Women with low education attainment and those with the lowest socioeconomic status have one child more than the country average (3.4 and 3.5 children per woman, respectively). Executive Summary vii  Generally, peak fertility occurred at ages 30–34 among women with the highest educational attainment, whereas peak fertility among women with lower educational levels occurred at ages 20–24. Similarly, women with the highest socioeconomic status postpone their fertility until after the age of 30, compared to peak fertility at age 20–24 among those with lower socioeconomic status.  Due to the impressive changes in the contraceptive uptake, the percentage of births that were unintended was the lowest ever documented: less than one half (47%) of births in the last 5 years were unintended, compared to 58% in 2008. Maternal and Infant Health:  Coverage of prenatal care among all pregnancies carried to term since January 2003 was very high with only 1% of pregnant women indicating that they received no prenatal care. The majority of births (60%) received prenatal care during the first trimester, as recommended by the World Health Organization (WHO). In the Kingston metropolitan area, first trimester visits were even more common (74%).  WHO guidelines call for a minimum of four prenatal visits over the course of a woman’s pregnancy. In Jamaica, this was achieved in 87% of births, including 50% which were preceded by 10 or more visits.  Women with high-risk pregnancies, as defined by specific age and parity criteria established by the Ministry of Health, had mostly received inadequate (41%) or only partially adequate (18%) prenatal care. Increased educational attainment and socioeconomic status of the mother were positively correlated with receipt of adequate care. Most importantly, women with 5 or more births, who by definition are classified as having high pregnancy-related health risk, were less likely to have had adequate prenatal care than women with lower number of births.  The majority of women received most of their prenatal care from either governmental health clinics (72%) or maternity hospitals (4%). Almost one in five women (20%) mentioned they mostly received prenatal care in private clinics, and 3% received care in private hospitals.  Most births that have occurred since January 2003 were delivered in health care facilities with 93% taking place in a governmental hospital and less than five percent in other medical facilities. Almost all women reported that the person who attended their last delivery was either a midwife or nurse-midwife (65%) or a physician (33%), which is an indicator of progress towards Millennium Development Goal (MDG) 5, which aims to improve maternal health. viii Reproductive Health Survey, Jamaica 2008  Child survival in Jamaica has improved substantially over the past 10 years. A comparison of the two most recent 5-year periods shows that there has been a dramatic decline in the neonatal mortality rate (from 20.0 to 13.0 per 1,000), which in turn has significantly lowered the infant and child under-5 mortality. The highest infant and under-5 mortality rates were found among children living in rural areas, those born to mothers who have low educational attainment, and those born less than 24 months apart. Contraceptive Knowledge:  Women of reproductive age in Jamaica are well aware of contraceptive methods with virtually all respondents having heard of at least one modern method. Since 1989, the three most well-known methods have been the male condom, oral contraceptive pills, and injectables.  The most notable change in knowledge was found for emergency hormonal contraception (morning after pill) with knowledge of emergency contraception increasing by 82% (from 49% to 89%) between 2002 and 2008.  Young men’s knowledge of the most commonly known methods of contraception has improved slightly since 1993. Similar to women, the most notable change in men’s knowledge was the increase in awareness of emergency hormonal contraception by 65% (from 39% in 2002 to 64% in 2008).  Attitudes about family formation and timing of births are closely related to knowledge and use of family planning methods. In the 2008 RHS, more than half (54%) of women preferred an interval of more than 4 years, followed by 2 to 4 years (37%). Contraceptive Use:  Ever use of contraceptive methods remains high with 85% of women having experience using a contraceptive method.  Experience of ever using contraceptives is high regardless of education level, ranging from 82% of women with 9 or fewer levels of education achieved up to 88% for women at level 13 or higher.  Seventy-three percent of women currently in union reported current use of contraceptives and almost a quarter (22%) of them were using a secondary contraceptive method. Executive Summary ix  More reliable, modern methods are the most commonly used with 84% of women having ever used a modern method. Among current contraceptive users, the most popular methods were condom, the pill and injectables. Almost one half of users (47%) rely on condoms, which provides dual protection against unintended pregnancy and sexually transmitted diseases. In comparison to previous years, more women are beginning contraceptive use prior to their first birth. Sixty-five percent of women had no children when they first used a contraceptive method, compared to only 54% in the 2002 and 1997 surveys.  There has been a significant improvement in the availability of family planning services at government facilities since the 2002 survey. Over half of women (51%) said these services were available at any time, up from 31%.  Among sexually experienced women who were not using contraception, 57% reported that they intend to use a method in the future. Condom Use:  Virtually all (100%) women aged 15-49 years had heard of condoms, 77% had ever used a condom, and 20% reported currently using condoms. Of women who had sexual intercourse in the last 12 months, 42% reported using a condom the last time.  Knowledge of condoms among young men aged 15-24 was also extremely high with 100% having ever heard of condoms, 73% reporting ever having used condoms, and 43% reporting current condom use. Among men who had sexual intercourse in the 12 months prior to the survey, 80% reported having used a condom the last time. Compared to young women in the same age group, young men had higher use prevalence of ever use, current use, and use at last intercourse.  Among respondents who had sex with a non-steady partner, 64% of women and 91% of young men reported that they use condoms every time or almost every time. One-fifth (21%) of women with a non-steady partner said that they never use a condom and almost no men stated that they never used a condom (1%).  Most sexually active women (72%) report having ever asked a partner to use a condom. Of those who had, some negative reactions incurred were refusal to use a condom (20.6%), forced sex without condom (8%), partners refusal to have sex (7%) a threat to end the relationship (3%) and a threat of physical harm (1%). A woman’s increased level of education is related to an increased likelihood in her suggesting condom use and a decreased likelihood of negative reactions from her partner. x Reproductive Health Survey, Jamaica 2008  Approximately a tenth (9%) of women said they used condoms to prevent pregnancy, 19% to prevent STIs, including HIV, and 72% said it was to prevent both. A higher proportion of young men than young women in their same age group reported that the objective of their condom use was dual protection Health-Related Behaviors:  Only 43% of reproductive aged women (15-49 years) reported ever having a routine gynecological exam and 62% had received a pap smear test to screen for cervical cancer. There has been very little improvement in the prevalence of preventive reproductive health practices since 2002.  Nearly two-thirds (62%) of women reported having ever had a clinical screening for breast cancer, and 64.6% reported having ever performed a breast self-exam (BSE) at some point in their life. Both clinical and self exams were associated with age older than 19 years, higher educational attainment and socio-economic index, having a steady partner (excluding a boyfriend), and being sexually experienced.  The most common health conditions reported by women of reproductive age were high blood pressure (20%), urinary tract infection (12.6%), asthma (8.8%), anemia (8.6%), and diabetes (4.4%). For these conditions, women with a higher education level are more likely to report health problems, possibly due to better access to health care providers.  Similar to the findings from 2002, in the current survey 6% of women aged 15–49 years reported having ever smoked and 3.5% were current smokers. When compared to men aged 15–24 years, women of the same age group were less likely to have ever smoked and to smoke currently, and young women started smoking one year later than young men (17 vs. 16 years old).  Recreational drug use in the last 12 months was much more frequent among young men when compared to young women of the same age: 14.1% and 31.1% of men aged 15-19 and 20-24, respectively, vs. 3.3% and 7.2% of their female counterparts. Young Adults:  The proportion of young adults who are sexually experienced has decreased, with 66% of young women and 75% of young men having ever had sex, compared to 69% of young women and 82% of young men in 2002. This reflects a trend of decreased sexual experience since the 1993 survey. Executive Summary xi  Young adults are also waiting longer to initiate sex. The mean age at first intercourse was 16.1 for young women and 14.5 for young men, compared to 15.8 and 13.5, respectively, in 2002. This is the largest change in this indicator since the 1993 survey. However, 12% of young women and three times as many young men (35%) reported starting sexual activity before age 15.  The use of contraception at first sexual intercourse among sexually experienced young women has continuously increased to 79%, compared to 67% in 2002, 56% in 1997, and 43% in 1993. That improvement has been similar in young men increasing from 22% in 1993 to 56% in 2008.  Contraceptive use at most recent sexual intercourse among sexually experienced young adults was 82% among women and 84% among men. That use is overwhelmingly modern methods use, with condoms being most commonly used among young adults (43% of young women and 74% of young men).  The percent of young adults who received school-based or other formal family life education has increased since the previous surveys. Ninety percent of young women and 84% of young men received family life education in school or in another formal setting. Sexually transmitted infections, including HIV/AIDS:  Awareness of STIs was generally high with 100% of women reporting awareness of HIV/AIDS, 100% of Gonorrhea, and 98% of syphilis; however, only 29% knew of chancroid and 45% knew of chlamydia. Young women were more likely to report awareness of most STIs than were young men. Young men were also less likely to know symptoms of STIs.  The most important sources of information about STIs for women were health professionals (23%), television (22%), teachers (14%), and printed media (11%). This differed among young people, men and women, who placed higher importance on teachers and family members and lower importance on health professionals.  Having multiple sexual partners, whether in the last 3 months or the last year, was uncommon among women (4% and 7% respectively). Young men were much more likely to report having multiple partners in the last 3 or 12 months than young women.  Among young adult women and men with multiple partners in the last 12 months, a substantial proportion (46 % and 22%, respectively) did not use condoms at the last sexual encounter. In these same groups, use of alcohol and/or drugs at the time of the last sexual encounter was reported by 26.5% of young women and 18.0% of young men. xii Reproductive Health Survey, Jamaica 2008  When women were asked about maternal to child transmission (MTCT) of HIV, knowledge of the facts varied with 85% aware that it can be transmitted during pregnancy, 74% aware that it can be transmitted during delivery, and 82% aware that it can be transmitted through breastfeeding. Over two-thirds of women (69%) knew that drugs were available to reduce MTCT.  The percentages of respondents who were able to correctly identify all three methods of HIV prevention were 85% of women and 78% of men. When restricted to young adults, young women were more likely than young men to correctly provide answers to all three items (87% of girls 15-19 years old and 84% of young women 20-24 years old versus 79% of boys 15-19 years old and 75% of young men 20-24 years old).  Practically all women (95%) knew where HIV testing is provided, a little less than two- thirds (60%) reported ever having been tested and receiving their results, and a quarter (26%) reported that their last HIV-test took place within 12 months of the interview.  HIV testing has been successfully integrated with prenatal care. Nine out of ten women (91%) who had been pregnant since January 2006 or were at least six months pregnant at the time of the survey, and had prenatal care, reported that they had been tested for HIV.  Respondents were asked about different hypothetical situations involving interactions with HIV-infected individuals. Ninety percent of women and 88% of young men indicated that they would be willing to work with a co-worker who was infected with the AIDS virus. Less tolerant attitudes were found among 29% of women and 25% of young men who stated they would want it kept a secret if a relative became infected with the AIDS virus. Gender Attitudes and Violence against Women:  Jamaican men aged 15–24 years had a tendency toward more traditional attitudes about gender norms when compared to young women in the same age group. Sizeable opinion gaps were also seen between young men and young women when it came to the importance of a man showing his wife/partner who is the boss, the acceptability of a wife’s refusal to have sex with her husband if he sees other women, the notion that a good wife should obey her husband even if she disagrees with him, and on the question of whether family problems should be discussed only with family members.  Overall, 18% of women reported that they witnessed violence between their parents, and 61.2% reported that they had been slapped, kicked, shoved, or hit by a parent or step-parent before age 15. Fourteen percent of Jamaican men aged 15–24 years Executive Summary xiii witnessed violence between their parents and 58% reported having experienced physical abuse from a parent or stepparent.  Almost half (48%) of women reported that a current or former spouse subjected them to at least one controlling behavior. Experience of multiple controlling behaviors was strongly associated with all types of intimate partner violence, including physical violence.  During the past year, 14.7% of women ever in union reported verbal abuse, 6.5% reported physical abuse, and 2.8% reported sexual abuse.  Overall, 12% of Jamaican women reported having been physically forced to have sexual intercourse at some time in their life. The majority of perpetrators were known to the woman, including current or previous partners (36%), acquaintances (20%), boyfriends or ex-boyfriends (18%), and relatives (10%). Only one in eight (12%) women who has ever been raped reported having been raped by a stranger. xiv Reproductive Health Survey, Jamaica 2008 Table of Contents xv Table of Contents Preface . iii Institutional Participation . iv Executive Summary. v Table of Contents . xv List of Tables . xix List of Figures . xxxiii Chapter 1: Background . 1 1.1 Historical, Geographical, and Demographic Background . 1 1.2 Population Policies and Programs . 4 1.3 Survey Objectives . 5 1.4 Institutional Participation . 8 1.5 Sampling Design . 10 1.6 Response Rates . 13 1.7 Sampling Weights . 15 Chapter 2: Characteristics of the sample . 17 2.1 Age . 18 2.2 Partnership Status . 19 2.3 Education Level . 20 2.4 Wealth Quintile . 21 2.5 Employment Status . 21 2.6 Church Attendance . 22 2.7 Number of Children Born Alive . 23 Chapter 3: Fertility and Fertility-Related Factors . 37 3.1 Fertility Levels, Trends, and Differentials . 37 3.2 Teenage Pregnancy . 41 3.3 Age at Menarche and Sexual Experience . 42 3.4 Age at First Intercourse, Union, and Birth . 44 3.5 Recent Sexual Activity . 46 3.6 Postpartum Amenorrhea, Abstinence and Insusceptibility . 50 Page xvi Reproductive Health Survey, Jamaica 2008 3.7 Planning Status of the Last Pregnancy . 53 3.8 Future Fertility Preferences . 58 Chapter 4: Maternal and Infant Health . 83 4.1 Prenatal Care . 83 4.2 Delivery Care . 90 4.3 Smoking and Drinking During Pregnancy . 91 4.4 Infant and Child Mortality . 92 Chapter 5: Contraceptive Knowledge . 107 5.1 Knowledge of Contraceptive Methods . 107 5.2 Ideal Birth Interval . 110 Chapter 6: Contraceptive Use . 117 6.1 Ever Use of Contraceptives . 117 6.2 First Use of Contraceptives . 119 6.3 Current Use of Contraceptives . 120 6.4 Source of Contraceptives . 125 6.5 Desire to Use a Different Contraceptive Method . 126 6.6 Intention to Use Contraceptives among Non-users . 127 6.7 Contraceptive Failure and Discontinuation . 127 Chapter 7: Hormonal Contraceptive Use . 163 7.1 Pill Use and Opinions about its Effectiveness and Safety . 163 7.2 Use of Emergency Hormonal Contraception and Opinions about its Effectiveness and Safety . 165 7.3 Use of Injectables and Opinions about its Effectiveness and Safety . 166 Chapter 8: Condom Use . 175 8.1 Condom Use . 175 8.2 Reasons for Use . 177 8.3 Opinions about Effectiveness and Safety of Condom Use . 177 Chapter 9: Contraceptive Sterilization: Use and Demand . 197 9.1 Characteristics of Sterilized Women . 198 9.2 Satisfaction with Sterilization . 200 9.3 Interest in Sterilization . 201 9.4 Reasons for Not Using Sterilization . 203 Chapter 10: Non-Use of Contraceptives . 213 10.1 Reasons for Not Using a Contraceptive Method . 213 Table of Contents xvii 10.2 Need for Family Planning Services . 215 Chapter 11: Health-Related Behaviors . 223 11.1 Routine Gynecologic Visits . 223 11.2 Cervical Cancer Screening . 224 11.3 Breast Cancer Screening . 226 11.4 Selected Health Problems . 227 11.5 Smoking and Alcohol and Drug Use . 227 Chapter 12: Young Adults . 241 12.1 Characteristics of the Young Adults . 241 12.2 Exposure to Sexual Experience . 242 12.3 First Sexual Intercourse . 243 12.4 Contraceptive Use and Non-Use at First Sexual Intercourse . 248 12.5 Use of Contraception at Most Recent Sexual Intercourse . 250 12.6 Discussions about Family Life Education Topics with Parents . 254 12.7 Exposure to Formal Family Life Education . 256 12.8 Other Sources of Information on Sex, Contraception, and STIs . 258 12.9 Resiliency against High-Risk Behaviors . 261 12.10 Impact of Family Life Education on Reproductive Health Knowledge and Attitudes . 263 Chapter 13: Sexually Transmitted Infections . 315 13.1 Awareness and Knowledge of STIs . 315 13.2 Source of Information about STIs . 316 13.3 Self-Reported Experiences of STIs and STI Symptoms . 317 13.4 Risky Sexual Behaviors . 318 13.5 Self-Perceived Risk of STIs . 320 Chapter 14: HIV/AIDS . 337 14.1 Awareness and Knowledge of HIV/AIDS . 337 14.2 HIV-testing . 341 14.3 Self-perceived Risk of HIV/AIDS . 343 14.4 Stigma toward HIV-infected Persons . 345 Chapter 15: Gender Attitudes and Violence against Women . 369 15.1 Attitudes about Gender Norms . 370 15.2 Attitudes and Practice of Child Punishment . 372 15.3 History of Witnessing or Experiencing Parental Physical Abuse . 373 15.4 Intimate Partner Violence . 376 15.5 Consequences of Recent Physical and Sexual Violence and Coping Strategies . 380 xviii Reproductive Health Survey, Jamaica 2008 15.6 Correlates of Lifetime Physical Abuse . 383 15.7 Lifetime Experience of Forced Sexual Intercourse (Rape) by Any Perpetrator . 386 Female Questionnaire . 411 Male Questionnaire . 453 List of Tables xix List of Tables 1.1.1 Distribution of the Population by Health Region In 1992, 1996, 2001 and 2008 (Percent Distribution) . 2 1.1.2 Age Distribution of the Total Population End of the Year 1992, 1996, 2001, and 2008 (Percent Distribution) . 3 1.1.3 Percentage of the Population in Urban Areas End of the Year 1970, 1982, 1991, 2001, and 2008 . 3 1.5 Number of Households (HH) in the Jamaica RHS08 Sample and the 2001 Census and the Ratio of the Number of Households in the Census to the Number of Households in the Sample, by Parish . 11 1.6A Results of Household Visits and Individual Interview Status of Eligible Women Aged 15–49 Years by Residence and Health Region (Percent Distribution) . 13 1.6B Results of Household Visits and Individual Interview Status of Eligible Men Aged 15–24 Years by Residence and Health Region (Percent Distribution) . 14 2.2A Current Partnership Status among Women Aged 15–49 Years by Selected Characteristics . 25 2.2B Current Partnership Status of Men Aged 15–24 Years by Selected Characteristics . 26 2.3A Education Level among Women Aged 15–49 Years by Selected Characteristics . 27 2.3B Education Level of Men Aged 15–24 Years by Selected Characteristics . 28 2.4A Percentage Distribution of Women Aged 15–49 Years by the Wealth Quintile of Their Households by Selected Characteristics . 29 2.4B Percentage Distribution of Men Aged 15–24 Years by the Wealth Quintile of Their Households by Selected Characteristics . 30 2.5A Employment Status among Women Aged 15–49 Years by Selected Characteristics . 31 2.5B Employment Status of Men Aged 15–24 Years by Selected Characteristics . 32 2.6A Frequency of Church Attendance among Women Aged 15–49 Years by Selected Characteristics . 33 2.6B Frequency of Church Attendance among Men Aged 15–24 Years by Selected Characteristics . 34 2.7A Number of Children Born Alive among Women Aged 15–49 Years by Selected Characteristics . 35 2.7B Number of Children Born Alive among Men Aged 15–24 Years by Selected Characteristics . 36 3.1.1 Age-Specific Fertility Rates and Total Fertility Rates by Age at Birth Reproductive Health Surveys, Contraceptive Prevalence Surveys, and the World Fertility Survey Jamaica, 2008–1975 . 60 Table Page xx Reproductive Health Survey, Jamaica 2008 3.1.2 Age-Specific Fertility Rates and Total Fertility Rates by Selected Characteristics . 61 3.1.3 Childlessness among Women 15–49 Years of Age by Current Age Group and Selected Characteristics . 62 3.2 Pregnancy and Motherhood Experience among Women 15–19 Years of Age by Selected Characteristics . 63 3.3.1 Mean Age at First Menstrual Period among Women Aged 15–49 Years by Selected Characteristics . 64 3.3.2 Perceived Best Age to Start Family Life and Sexual Education in School by Selected Characteristics, Women Aged 15–24 Years. 65 3.3.3 Percentage of Women Aged 15–49 Years Who Have Ever Had Sexual Relations by Selected Characteristics . 66 3.4.1 Percentage of Women Aged 15–49 Years Who Had Their First Sexual Relation, First Union, and First Birth before Selected Ages and Median Age at First Sexual Relation, First Union, and First Birth by Current Age Group . 67 3.4.2 Perceived Best Age at Which Women Are Responsible Enough to Start Childbearing among Women Aged 15–49 Years by Selected Characteristics . 68 3.5.1 Current Sexual Activity among All Women Aged 15–49 Years and Men Aged 15–24 Years by Current Relationship Status Reproductive Health Survey: Jamaica, 2008, 2002, 1997 . 69 3.5.2 Current Sexual Activity among Sexually Experienced Women Aged 15–49 and Men Aged 15–24 Years by Selected Characteristics . 70 3.5.3A Relationship with the Last Sexual Partner among Sexually Experienced Women Aged 15–49 Years by Current Relationship Status . 71 3.5.3B Relationship with the Last Sexual Partner among Sexually Experienced Men Aged 15–24 Years by Current Relationship Status . 72 3.5.4 Relationship with the Last Sexual Partner among Women 15–49 Years Who Had Sexual Relations in the Last 12 Months by Selected Characteristics . 73 3.5.5 Relationship with the Last Sexual Partner among Women 15–49 Years Who Had Sexual Relations in the Last 30 Days by Selected Characteristics. 74 3.5.6 Percentage of Women Aged 15–49 Years Who Were Not Currently Sexually Active and Had Sexual Intercourse in the Past Three Months by Current Relationship Status . 75 3.6.1 Percentage of Women Aged 15–49 Years Who Gave Birth in the 24 Months Prior to the Survey and Were Postpartum Amenorrheic, Postpartum Abstinent, or Postpartum Insusceptible by the Number of Months since Birth . 76 3.6.2 Percentage of Women Aged 15–49 Years Who Gave Birth in the 24 Months Prior to the Survey and Were Postpartum Amenorrheic, Postpartum Abstinent, or Postpartum Insusceptible by Selected Characteristics . 77 3.6.3 Duration of Postpartum Abstinence among Women Aged 15–49 Years Who Gave Birth in 2003–2008 by Selected Characteristics . 78 3.6.4 Opinions about the Ideal Duration of Breastfeeding among Women Aged 15–49 Years by Selected Characteristics . 79 Page Table List of Tables xxi 3.7 Planning Status of Current Pregnancies and Most Recent Pregnancies Resulting in a Live Birth in the Last 5 Years among Women Aged 15–49 Years by Selected Characteristics . 80 3.8 Desired Number of Additional Children among Sexually Experienced Women Aged 15–49 Years by Current Number of Living Children . 81 4.1.1 Initiation of Prenatal Care by Pregnancy Trimester and Number of Prenatal Visits among Women Aged 15–49 Who Gave Birth in 2003–2008 by Selected Characteristics . 95 4.1.2 Adequacy of Prenatal Care for High-risk Pregnancies Resulted in Live Births in 2003–2008 by Selected Characteristics . 96 4.1.3 Percentage of WomenAged 15–49 Years Who Gave Birth in 2003–2008 and Were Vaccinated against Tetanus during Pregnancy and Number of Doses Given . 97 4.1.4 Routine Screening of Blood Pressure during Pregnancy and Experience of High Blood Pressure during Pregnancy by Selected Characteristics . 98 4.1.5 Experience of HIV-Testing during Prenatal Care among Recently Pregnant Women† Aged 15–49 Years by Selected Characteristics . 99 4.1.6 Place of Most Prenatal Care for Women Aged 15–49 Years Who Gave Birth in 2003–2008 by Selected Characteristics . 100 4.2.1 Place of Delivery for Births in 2003–2008 by Selected Characteristics . 101 4.2.2 Principal Person Who Assisted at Delivery of the Last Birth in 2003–2008 by Selected Characteristics . 102 4.2.3 Percentage of Births in 2003–2008 Delivered by Cesarean Section by Selected Characteristics . 103 4.3 Prevalence of Smoking and Drinking during the Last Pregnancy and Number of Cigarretes Smoked among Women Aged 15–49 Who Gave Birth in 2003–2008 by Selected Characteristics . 104 4.4 Infant and Child Mortality Rates (Infant and Child Deaths per 1,000 Live Births) among Children Born in the Last 10 Years (June 1998–May 2008) by Selected Characteristics . 105 5.1.1A Contraceptive Awareness among Women Aged 15–49 Years by Specified Contraceptive Method . 111 5.1.1B Contraceptive Awareness among Adult Men Aged 15–24 by Specified Contraceptive Method . 112 5.1.2 Contraceptive Awareness among Women Aged 15–49 Years by Specified Contraceptive Method and Age Group . 113 5.1.3 Contraceptive Awareness among Women Aged 15–49 Years by Specified Contraceptive Method and Area of Residence . 114 5.1.4 Contraceptive Awareness among Women Aged 15–49 Years by Specified Contraceptive Method and Education Level . 115 5.2 Opinions about the Ideal Interval between Births among Women Aged 15–49 Years by Select Characteristics . 116 Page Table xxii Reproductive Health Survey, Jamaica 2008 6.1.1 Ever-Use of Contraceptive Methods among Women Aged 15–49 Years by Selected Characteristics . 129 6.1.2 Ever-Use of Contraceptive Methods among Women Aged 15–49 Years by Specified Contraceptive Method Used and by Survey Year. 130 6.1.3 Ever-Use of Contraceptive Methods among Aged 15–49 Years by Specified Contraceptive Method Used and by Area of Residence . 131 6.1.4 Ever-Use of Contraceptive Methods among Women Aged 15–49 Years by Specified Contraceptive Method Used and by Parish of Residence . 132 6.1.5 Ever-Use of Contraceptive Methods among Women Aged 15–49 Years by Specified Contraceptive Method Used and by Health Region . 133 6.1.6 Ever-Use of Contraceptive Methods among Women Aged 15–49 Years by Specified Contraceptive Method Used and by Age Group . 134 6.1.7 Ever-Use of Contraceptive Methods among Women Aged 15–49 Years by Specified Contraceptive Method Used and by Number of Children Born Alive . 135 6.1.8 Ever-Use of Contraceptive Methods among Women Aged 15–49 Years by Specified Contraceptive Method Used and by Education Level . 136 6.2.1 Mean Age (in Years) at the Time When Women Aged 15–44 Years First Used a Contraceptive Method by Selected Characteristics . 137 6.2.2 Number of Living Children at First Use of a Contraceptive Method among Women Aged 15–44 Years by Selected Characteristics . 138 6.3.1 Current Contraceptive Use among All Women and Women Currently in Union Aged 15–49 Years by Selected Characteristics. 139 6.3.2 Current Contraceptive Use among All Women and Women Currently in a Union Aged 15–49 Years by Specified Contraceptive Method . 140 6.3.3 Mean Age of All Women and Women Currently in a Union Aged 15–44 Years among Current Users of Selected Contraceptive Methods . 141 6.3.4 Current Contraceptive Use among All Women and Women Currently in Union Aged 15–49 Years by the Type of Method by Selected Characteristics . 142 6.3.5 Current Contraceptive Use of Specified Methods among All Women Aged 15–49 Years by the Relationship Status . 143 6.3.6 Current Contraceptive Use among All Women and Women Currently in Union Aged 15–49 Years by Health Region and Method . 144 6.3.7 Current Contraceptive Use among All Women and Women Currently in Union Aged 15–49 Years by Age Group and Method . 145 6.3.8 Current Contraceptive Use among All Women and Women Currently in Union Aged 15–49 Years by Number of Live Births and Contraceptive Method . 146 6.3.9 Current Contraceptive Use among All Women and Women Currently in Union Aged 15–49 Years by Education Level and Method . 147 6.3.10 Current Contraceptive Use among All Women and Women Currently in Union Aged 15–49 Years by Frequency of Church Attendance and Method . 148 6.3.11 Current Use of a Secondary Contraceptive Method among All Women and Women Currently in Union Aged 15–49 Years by Select Characteristics . 149 Page Table List of Tables xxiii 6.3.12 Current Use of a Secondary Contraceptive Method among All Women and Women Currently in Union Aged 15–49 Years by Primary and Secondary Method Used . 150 6.3.13 Current Contraceptive Use and Concurrent Use of a Secondary Contraceptive Method among All Women and Women in Union Aged 15–49 Years by Select Characteristics . 151 6.4.1 Source of Supply for Selected Contraceptive Methods among All Women and Women Currently in Union Aged 15–49 Years Who Are Currently Using Modern Methods by Residence and Method . 152 6.4.2 Source of Supply for Selected Contraceptive Methods among Women Aged 15–49 Years Not Currently in Union Who Are Currently Using Selected Modern Methods . 153 6.4.3 Availability of Family Planning Services at the Government Clinics or Health Centres for All Women Aged 15–49 Years Who Obtain Contraception from Government Sources by Selected Characteristics . 154 6.4.4 Length of Travel Time to a Source of Contraception for All Women Aged 15–49 Years Who Are Currently Using a Supplied Method by Selected Characteristics . 155 6.5.1 Desire to Use a Different Contraceptive Method and the Specified Prefered Method among Women Currently in Union Aged 15–49 Years Who Are Currently Using Contraception by Selected Characteristics . 156 6.5.2 Most Commonly Cited Reasons for Not Using the Prefered Method among Women Currently in Union Aged 15–49 Years Who Are Currently Using Contraception and Desire to Switch to Another Method by Selected Characteristics . 157 6.6.1 Desire to Use Contraception in the Future among Sexually Experienced Women Aged 15–49 Years Who Are Not Currently Using Contraception by Select Characteristics . 158 6.6.2 Prefered Future Contraceptive Method among Sexually Experienced Women Aged 15–49 Years Who Are Not Currently Using Contraception by Select Characteristics . 159 6.7.1 Contraceptive Failure and Discontinuation Rates after One, Two and Three Years for Selected Methods of Contraception—All Segments of Contraceptive Use Initiated since January 2003 . 160 6.7.2 Contraceptive Discontinuation Rates After One Year by Primary Reason for Discontinuing Contraception for Selected Methods of Contraception - All Segments of Contraceptive Used Initiated Since January 2003 . 161 7.1.1 Awareness of Pill among All Women Aged 15–49 Years and Use among Those Who Had Sexual Intercourse in the Past 12 Months by Selected Characteristics . 167 7.1.2 Brand of Pill Used by Women Aged 15–49 Years Who Were Currently Using the Pill by Area of Residence . 168 7.1.3 Brand of Pill Used by Women Aged 15–49 Years Who Were Currently Using the Pill by Selected Characteristics . 169 Page Table xxiv Reproductive Health Survey, Jamaica 2008 7.1.4 Perceptions about the Pill's Effectiveness to Prevent Pregnancy among Women Aged 15–49 Years by Selected Characteristics. 170 7.1.5 Opinions on the Level of Health Risk Associated with Using the Pill among Women Aged 15–49 Years by Selected Characteristics . 171 7.2 Awareness and Ever Use of Hormonal Emergency Contraception among Women Aged 15–49 Years by Selected Characteristics . 172 7.3.1 Perceptions about the Effectiveness of the Injectables to Prevent Pregnancy among Women Aged 15–49 Years by Selected Characteristics . 173 7.3.2 Opinions on the Level of Health Risk Associated with Using the Injectables among Women Aged 15–49 Years by Selected Characteristics . 174 8.1.1A Awareness and Use of Condom among Women Aged 15–49 Years by Selected Characteristics . 179 8.1.1B Awareness and Use of Condom among Men Aged 15–24 Years by Selected Characteristics . 180 8.1.2A Frequency of Condom Use with a Steady Partner among Women Aged 15–49 Years Who Used Condoms in the Last 12 Months by Selected Characteristics . 181 8.1.2B Frequency of Condom Use with a Steady Partner among Men Aged 15–24 Years Who Used Condoms in the Last 12 Months by Selected Characteristics . 182 8.1.3A Frequency of Condom Use with a Non-Steady Partner among Women Aged 15–24 Years Who Used Condoms in the Last 12 Months by Selected Characteristics . 183 8.1.3B Frequency of Condom Use with a Non-Steady Partner among Men Aged 15–24 Years Who Used Condoms in the Last 12 Months by Selected Characteristics . 184 8.1.4A History of Ever Asking a Partner to Use a Condom and Selected Partner's Reactions to the Woman's Request among Sexually Experienced Women Aged 15–49 Years by Selected Characteristics . 185 8.1.4B History of Ever Suggesting to Use a Condom with a Female Partner and Selected Partner's Reactions to This Suggestion among Sexually Experienced Men Aged 15–24 Years by Selected Characteristics . 186 8.1.5 History of Ever Being Asked to Use a Condom by a Female Partner and Selected Man's Reactions to the Request among Sexually Experienced Men Aged 15–24 Years by Selected Characteristics . 187 8.2A Main Reasons for Using Condoms among Women Aged 15–49 Years Who Have Used Condoms in the Last 12 Months by Selected Characteristics . 188 8.2B Main Reasons for Using Condoms among Men Aged 15–24 Years Who Have Used Condoms in the Last 12 Months by Selected Characteristics . 189 8.3.1A Perceptions about the Condom's Effectiveness to Prevent Pregnancy among Women Aged 15–49 Years by Selected Characteristics . 190 8.3.1B Perceptions about the Condom's Effectiveness to Prevent Pregnancy among Men Aged 15–24 Years, by Selected Characteristics . 191 8.3.2A Perceptions about Condom's Effectiveness to Prevent Sexually Transmitted Infections among Women Aged 15–49 Years by Selected Characteristics . 192 Page Table List of Tables xxv 8.3.2B Perceptions about Condom's Effectiveness to Prevent Sexually Transmitted Infections among Men Aged 15–24 Years by Selected Characteristics . 193 8.3.3A Opinions on the Level of Health Risk Associated with Using the Condom among Women Aged 15–49 Years by Selected Characteristics . 194 8.3.3B Opinions on the Level of Health Risk Associated with Using the Condom among Men Aged 15–24 Years by Selected Characteristics . 195 9.1.1 Characteristics of Women in Union Aged 15–44 Years and Characteristics of Sterilized and Non-Sterilized Women in Union Aged 15–44 Years (Percent Distribution) . 205 9.1.2 Age and Number of Children Born Alive at the Time of the Female Sterilization Procedure among All Women and Women in Union Aged 15–44 Years (Percent Distribution) . 206 9.1.3 Mean Number of Children Born Alive among Sterilized and Non-Sterilized Women Aged 15–49 Years by Current Age Group . 207 9.2 Percentage of Contraceptively Sterilized Women Aged 15–49 Years Who Were Not Satisfied With the Sterilization Procedure by Selected Characteristics . 208 9.3.1 Interest in Female Sterilization among Fecund Women Aged 15–49 Years Who Do Not Want Any More Children by Selected Characteristics . 209 9.3.2 Interest in Female Sterilization after Completing the Desired Family Size among Fecund Women Aged 15–49 Years Who Want or Might Want More Children by Selected Characteristics . 210 9.4.1 Most Commonly Cited Reasons for Not Being Interested in Female Sterilization among Fecund Women Aged 15–49 Years Who Do Not Want Any More Children by Age Group and Education Level . 211 9.4.2 Most Commonly Cited Reasons for Not Being Interested in Female Sterilization after Completing the Desired Family Size among Fecund Women Aged 15–49 Years Who Want or Might Want More Children by Age Group and Education Level . 212 10.1.1 Most Commonly Cited Reasons for Not Currently Using Contraceptive Methods among Women Aged 15–49 Years . 218 10.1.2 Most Commonly Cited Reasons for Not Currently Using Contraceptive Methods among Women Aged 15–49 Years by Residence and Marital Status . 219 10.1.3 Percentage of Users of Selected Contraceptive Methods Who Would Prefer to Use a Different Contraceptive Method by Current and Preferred Method among Women Aged 15–49 Years . 220 10.2.1 Unmet Need for Family Planning Services among Women Aged 15–49 and 15–44 Years by Selected Characteristics . 221 10.2.2 Unmet Need for Family Planning Services among Women Aged 15–49 and 15–44 Years by Residence, Health Region and Parish . 222 11.1 Prevalence of Gynaecologic Examination and Time of Last Exam among Women Aged 15–49 Years, by Selected Characteristics. 231 Page Table xxvi Reproductive Health Survey, Jamaica 2008 11.2.1 Prevalence of Cervical Cancer Screening (Pap Spear Test) and Time of Last Exam among Women Aged 15–49 Years, by Selected Characteristics . 232 11.2.2 Medical Advise Following Cervical Cancer Screening among Women Aged 15–49 Years who Had Ever Had a Pap Smear Test,by Selected Characteristics . 233 11.3.1 Prevalence of Clinical and Breast Self–Exam (BSE) among Women Aged 15–49 Years, by Selected Characteristics . 234 11.3.2 Frequency of BSE among Women Aged 15–49 Years Who Reported Ever Performing BSE by Selected Characteristics . 235 11.4 Selected Health Problems Ever Been Told by a Doctor among Women Aged 15–49 Years, by Selected Characteristics . 236 11.5.1A Prevalence of Smoking among Women Aged 15–49 Years, by Selected Characteristics . 237 11.5.1B Prevalence of Smoking among Men Aged 15–24 Years, by Selected Characteristics . 238 11.5.2A Prevalence of Alcohol and Drug Use among Women Aged 15–49 Years, by Selected Characteristics . 239 11.5.2B Prevalence of Alcohol and Drug Use among Men Aged 15–24 Years, by Selected Characteristics . 240 12.1.1 Percent Distribution of Women and Men Aged 15–24 Years Interviewed in Reproductive Health Surveys by Age Group and Survey Year . 267 12.1.2 Employment Status of Women and Men Aged 15–24 Years by Age Group . 268 12.1.3 Current Relationship Status among Women and Men Aged 15–24 Years by Age Group . 269 12.2.1 Reported Sexual Experience of Women and Men Aged 15–24 Years by Current Age Group . 270 12.2.2 Reported Sexual Experience of Women and Men Aged 15–24 Years by Selected Characteristics . 271 12.3.1 Life-table Estimates of Age at First Sexual Experience among Women and Men Aged 15–24 Years by Selected Characteristics. 272 12.3.2 Mean Age at First Sexual Experience among Women and Men Aged 15–24 Years by Selected Characteristics . 273 12.3.3A Relationship to First Sexual Partner among Sexually Experienced Women Aged 15–24 Years by Age at First Sexual Experience . 274 12.3.3B Relationship to First Sexual Partner among Sexually Experienced Men Aged 15–24 Years by Age at First Sexual Experience . 275 12.3.4 Age Difference between Partners at First Sexual Experience among Women and Men Aged 15–24 Years by Selected Characteristics . 276 12.3.5A Duration of Dating before the First Sexual Experience among Women Aged 15–24 Years by Selected Characteristics . 277 12.3.5B Duration of Dating before the First Sexual Experience among Men Aged 15–24 Years by Selected Characteristics . 278 Page Table List of Tables xxvii 12.3.6 Prevalence of Coerced First Sexual Intercourse among Sexually Experienced Young Adults Aged 15–24 Years by Selected Characteristics . 279 12.4.1A Use of Contraception at First Sexual Experience among Women Aged 15–24 Years by Selected Characteristics . 280 12.4.1B Use of Contraception at First Sexual Experience among Men Aged 15–24 Years by Selected Characteristics . 281 12.4.2 Source of Condoms for Women and Men Aged 15–24 Years Who Had Used Condoms at First Sexual Experience . 282 12.4.3 Most Commonly Cited Reasons for Not Using Contraception at First Sexual Experience among Sexually Experienced Women and Men Aged 15–24 Years . 283 12.5.1 Current Sexual Activity Status among Sexually Experienced Women and Men Aged 15–24 Years . 284 12.5.2 Use of Contraception at Most Recent Sexual Intercourse in the Last 30 Days among Sexually Experienced Women and Men Aged 15–24 Years by Current Marital Status and Age Group . 285 12.5.3 Number of Sexual Partners During the Last 12 Months and Lifetime among Sexually Experienced Women and Men Aged 15–24 Years by Marital Status and Current Age . 286 12.5.4 Transactional Sex Reported by Sexually Experienced Women and Men Aged 15–24 Years by Selected Characteristics . 287 12.6.1 Percentage of Women Aged 15–24 Years Who Received Information about the Menstrual Cycle from a Parent or Step-parent and Their Opinion on How Difficult It Was to Discuss This Subject by Selected Characteristics . 288 12.6.2A Percentage of Women Aged 15–24 Years Who Received Information about Pregnancy and How It Occurs from a Parent or Step-parent and Their Opinion on How Difficult It Was to Discuss This Subject by Selected Characteristics . 289 12.6.2B Percentage of Men Aged 15–24 Years Who Received Information about Pregnancy and How It Occurs from a Parent or Step-parent and Their Opinion on How Difficult It Was to Discuss This Subject by Selected Characteristics . 290 12.6.3A Percentage of Women Aged 15–24 Years Who Received Information about Methods of Birth Control from a Parent or Step-parent and Their Opinion on How Difficult It Was to Discuss This Subject by Selected Characteristics . 291 12.6.3B Percentage of Men Aged 15–24 Years Who Received Information about Condom from a Parent or Step-parent and Their Opinion on How Difficult It Was to Discuss This Subject by Selected Characteristics . 292 12.7.1 Receipt of School-based or Other Formal Family Life Education (FLE) Courses among Women and Men Aged 15–24 Years by Current Age Group . 293 12.7.2 Specific FLE Topics and Information about Services for Adolescents Covered in the First School-based or Other Formal FLE Courses among Women and Men Aged 15–24 Years . 294 12.8.1A Preferred Source of Information about Family Life Education among Women Aged 15–24 Years by Selected Characteristics. 295 Page Table xxviii Reproductive Health Survey, Jamaica 2008 12.8.1B Preferred Source of Information about Family Life Education among Men Aged 15–24 Years by Selected Characteristics . 296 12.8.2 Opinions about How Helpful Specified Sources of Information on Family Life Education (FLE) Are among Women and Men Aged 15–24 Years . 297 12.8.3A Percentage of Women Who Have Seen or Heard of Programmes about Family Life Education in the Past 6 Months from Each Media Source among Women Aged 15–24 Years by Selected Characteristics. 298 12.8.3B Information on Family Life or Sexual Education Seen or Heard in the Past 6 Months among Men Aged 15–24 Years by Selected Characteristics and by Media Source . 299 12.8.4A Percentage of Women Aged 15–24 Years Who Reported a Behavior–Change Effect After Having Seen or Heard Information on Family Life or Sexual Education in the Past 6 Months by Selected Characteristics and by Media Source. 300 12.8.4B Percentage of Men Aged 15–24 Years Who Reported a Behavior-change Effect After They Had Seen or Heard Information on Family Life or Sexual Education in the Past 6 Months by Selected Characteristics and by Media Source . 301 12.8.5A Exposure to Selected Topics of Family Life or Sexual Education among Women Aged 15–24 Years Who Have Ever Seen or Heard Messages Distributed by the JA-STYLE Program by Selected Characteristics . 302 12.8.5B Exposure to Selected Topics of Family Life or Sexual Education among Men Aged 15–24 Years Who Had Ever Seen or Heard Messages Distributed by the JA-STYLE Program by Selected Characteristics . 303 12.8.6 Percentage of Women and Men Aged 15–24 Years Who Have Ever Received Health Counseling by Selected Characteristics and by Type of Counseling . 304 12.9.1A Percentage of Women Aged 15–24 Years Who Have Ever Participated in Community Activities for Adolescents by Selected Characteristics and by Type of Activities . 305 12.9.1B Percentage of Men Aged 15–24 Years Who Have Ever Participated in Community Activities for Adolescents by Selected Characteristics and by Type of Activities . 306 12.9.2A Percentage of Adolescent Women Aged 15–19 Years Reporting the Presence in the Household of an Adult with High Expectations and Carring Attitudes by Selected Characteristics . 307 12.9.2A Percentage of Adolescent Women Aged 15–19 Years Reporting the Presence in the Household of an Adult with High Expectations and Carring Attitudes by Selected Characteristics . 308 12.9.3A Percentage of Adolescent Women Aged 15–19 Years Reporting the Presence Outside the Home of an Adult with High Expectations and Caring Attitudes by Selected Characteristics . 309 Page Table List of Tables xxix 12.9.3B Percentage of Adolescent Men Aged 15–19 Years Reporting the Presence Outside the Home of an Adult with Caring Attitudes and High Expectations by Selected Characteristics . 310 12.9.4 Resilience Status in the Home and Outside the Home among Adolescent Women and Men Aged 15–19 Years by Selected Characteristics . 311 12.10.1 Correct Knowledge about the Most Likely Time to Become Pregnant during the Menstrual Cycle and Knowledge about the Effectiveness of the Pill and Injectables among Women and Men Aged 15–24 Years by Selected Characteristics . 312 12.10.2 Comprehensive Knowledge about HIV, Knowledge of a Place Where People Can Get Tested for HIV, and Knowledge of a Place Where Treatment for STIs Is Offered among Women and Men Aged 15–24 Years by Selected Characteristics . 313 12.10.3 Disagreement with Traditional Gender Roles and Opposition to Intimate Partner Violence (IPV) among Women and Men Aged 15–24 Years by Selected Characteristics . 314 13.1.1A Awareness of STIs among Women Aged 15–49 Years, by Selected Characteristics . 321 13.1.1B Awareness of STIs among Women Aged 15–49 Years, by Selected Characteristics . 322 13.1.2A Awareness of STI Symptoms among Women Aged 15–49 Years, by Selected Characteristics . 323 13.1.2B Awareness of STI Symptoms among Women Aged 15–49 Years, by Selected Characteristics . 324 13.2A Most Important Source of Information on STIs among Women Aged 15–49 Years, by Selected Characteristics . 325 13.2B Most Important Source of Information on STIs among Men Aged 15–24 Years, by Selected Characteristics . 326 13.3.1A Percentage of Women Aged 15–49 Years Who Have Ever Been Diagnosed with Specified STIs by Selected Characteristics . 327 13.3.1B Percentage of Men Aged 15–24 Years Who Have Ever Been Diagnosed with Specified STIs by Selected Characteristics . 328 13.3.2A Self–Reported STIs Symptoms among Women Aged 15–49 Years Who Had Sexual Intercourse in the Last 12 Months by Selected Characteristics . 329 13.3.2B Self–Reported STIs Symptoms among Men Aged 15–24 Years Who Had Sexual Intercourse in the Last 12 Months by Selected Characteristics . 330 13.3.3 Source of STI Treatment for Women Aged 15-49 Years Who Had Sexual Intercourse in the Last 12 Months and Experienced STI Symptoms by Selected Characteristics . 331 13.4A Risky Sexual Behaviors among Women Aged 15–49 Years Who Had Sexual Intercourse in the Last 12 Months by Selected Characteristics . 332 13.4B Risky Sexual Behaviors among Men Aged 15–24 Years Who Had Sexual Intercourse in the Last 12 Months by Selected Characteristics . 333 Page Table xxx Reproductive Health Survey, Jamaica 2008 13.5A Self–Perceived Risk of STIs among Women Aged 15–49 Years Who Had Sexual Intercourse in the Last 12 Months by Selected Characteristics . 334 13.5B Self–Perceived Risk of STIs among Men Aged 15–24 Years Who Had Sexual Intercourse in the Last 12 Months by Selected Characteristics . 335 14.1.1A Correct Knowledge of HIV/AIDS and Mother-to-Child-Transmission (MTCT) among Women Aged 15–49 Years by Selected Characteristics . 346 14.1.1B Correct Knowledge of HIV/AIDS and Mother-to-Child-Transmission (MTCT) among Men Aged 15-24 Years by Selected Characteristics . 347 14.1.2A Spontaneousely Mentioned Ways to Reduce the Risk of HIV Transmission among Women Aged 15-49 Years, by Selected Characteristics . 348 14.1.2B Spontaneousely Mentioned Ways to Reduce the Risk of HIV Transmission among Men Aged 15-24 Years, by Selected Characteristics . 349 14.1.3A Knowledge about Ways to Prevent the Sexual Transmission of HIV in Response to Prompted Questions among Women Aged 15-49 Years, by Selected Characteristics . 350 14.1.3B Knowledge about Ways to Prevent the Sexual Transmission of HIV in Response to Prompted Questions among Men Aged 15-24 Years, by Selected Characteristics . 351 14.1.4A Percentage of Women Aged 15-49 Years Who Correctly Reject Common Misconceptions about HIV Transmission by Selected Characteristics . 352 14.1.4B Percentage of Men Aged 15-24 Years Who Correctly Reject Common Misconceptions about HIV Transmission by Selected Characteristics . 353 14.2.1A Knowledge about Where HIV-Testing Is Provided and Experience of HIV-Testing among All Women Aged 15-49 Years, by Selected Characteristics . 354 14.2.1B Knowledge about Where HIV-Testing Is Provided and Experience of HIV-Testing among All Men Aged 15-24 Years, by Selected Characteristics . 355 14.2.2 Place of the Last HIV Test among Women Aged 15-49 Years Who Have Ever Been Tested by Selected Characteristics . 356 14.2.3A Willingness to Be HIV-Tested among Sexually Experienced Women Aged 15-49 Years Who Have Never Been Tested by Selected Characteristics . 357 14.2.3B Willingness to Be HIV-Tested among Sexually Experienced Men Aged 15-24 Years Who Have Never Been Tested by Selected Characteristics . 358 14.3.1A Self-Preceived Risk of HIV Infection among Women Aged 15-49 Years by Selected Characteristics . 359 14.3.1B Self-Preceived Risk of HIV Infection among Men Aged 15-24 Years by Selected Characteristics . 360 14.3.2A Self-Preceived Risk of HIV Infection among Sexually Experienced Women Aged 15-49 Years by Selected Characteristics . 361 14.3.2B Self-Preceived Risk of HIV Infection among Sexually Experienced Men Aged 15-24 Years by Selected Characteristics . 362 Page Table List of Tables xxxi 14.3.3A Most Commonly Cited Reasons for Self-Perceived Risk of HIV Transmission among Sexually Experienced Women Aged 15-49 Years by Selected Characteristics . 363 14.3.3B Most Commonly Cited Reasons for Self-Perceived Risk of HIV Transmission among Sexually Experienced Men Aged 15-24 Years, by Selected Characteristics . 364 14.3.4A Most Commonly Cited Reasons for No Self-Perceived Risk of HIV Transmission among Sexually Experienced Women Aged 15-49 Years by Selected Characteristics . 365 14.3.4B Most Commonly Cited Reasons for No Self-Perceived Risk of HIV Transmission among Sexually Experienced Men Aged 15-24 Years,by Selected Characteristics . 366 14.4A Accepting Attitudes toward Persons with HIV/AIDS among Women Aged 15-49 Years by Selected Characteristics . 367 14.4B Accepting Attitudes toward Persons with HIV/AIDS among Men Aged 15-24 Years by Selected Characteristics . 368 15.1.1A Agreement with Selected Attitudes Toward Gender Issues among Women Aged 15–49 Years by Selected Characteristics . 388 15.1.1B Agreement with Selected Attitudes Toward Gender Issues among Men Aged 15–24 Yearsby Selected Characteristics . 389 15.1.2A Agreement with Certain Circumstances That May Justify a Man Hitting His Wife among Ever-partnered Women Aged 15–49 Years by Selected Characteristics . 390 15.1.2B Agreement with Selected Circumstances That May Justify a Man Hitting His Wife among Ever-partnered Men Aged 15–24 Years by Selected Characteristics . 391 15.2A Attitudes towards Child Punishment among Women Aged 15–49 Years and Use of Psychological or Physical Punishment in Their Households by Type of Child Punishement Used in the Households and Selected Characteristics . 392 15.2B Attitudes towards Child Punishment among Men Aged 15–24 Years and Use of Psychological or Physical Punishment in Their Households by Type of Child Punishement Used in the Households and Selected Characteristics . 393 15.3A Percentage of Women Aged 15–49 Years Who Witnessed or Experienced Parental Physical Abuse before Age 15 by Selected Characteristics . 394 15.3B Percentage of Men Aged 15–24 Years Who Witnessed or Experienced Parental Physical Abuse before Age 15 by Selected Characteristics . 395 15.4.1A Experience of Selected Controlling Behaviors by Their Intimate Partners among Ever-partnered Women Aged 15–49 Years by Type of Behavior and Selected Characteristics . 396 15.4.1B Reports of Selected Controlling Behaviors towards Their Intimate Partners among Ever-partnered Men Aged 15–24 Years by Type of Behavior and Selected Characteristics . 397 15.4.2A Prevalence of Lifetime and Current (during the Last 12 Months) Intimate Partner Violence (IPV) by a Current or Former Partner among Ever-partnered Women Aged 15–49 Years by Type of Violence and Selected Characteristics . 398 Page Table xxxii Reproductive Health Survey, Jamaica 2008 15.4.2B Prevalence of Lifetime and Current (during the Last 12 Months) Intimate Partner Violence Perpetrated on Former or Current Partners among Ever-partnered Men Aged 15–24 Years by Type of Violence and Selected Characteristics . 399 15.4.3 Specific Acts of Verbal and Physical Violence Experienced by Ever-partnered Women Aged 15–49 Years during Lifetime by Selected Characteristics . 400 15.4.4 Different Combinations of Intimate Partner Violence Experienced by Ever-partnered Women Aged 15–49 Years during Lifetime and during the Last 12 Months . 401 15.5.1 Injuries Resulting from Episodes of Intimate Partner Violence among Ever-partnered Women Aged 15–49 Years Who Experienced Physical or Sexual Violence during the Last 12 Months by Selected Characteristics . 402 15.5.2 Percentage of Ever-partnered Women Aged 15–49 Who Experienced Recent Physical or Sexual Violence by an Intimate Partner and Had Missed Days of Work following Episodes of Violence by Selected Characteristics . 403 15.5.3 Percentage of Ever-partnered Women Aged 15–49 Who Experienced Recent Physical or Sexual Violence by an Intimate Partner and Have Talked about the Abuse with Family or Friends by Selected Characteristics . 404 15.5.4 Percentage of Ever-partnered Women Aged 15–49 Who Experienced Recent Physical or Sexual Violence by an Intimate Partner and Sought Institutional Help by Type of Place Where They Sought Help and Selected Characteristics . 405 15.5.5 Percentage of Ever-partnered Women Aged 15–49 Years Who Experienced Recent Physical or Sexual Violence by an Intimate Partner and Did Not Seek Institutional Help by Selected Reasons for Not Seeking Help and Selected Characteristics . 406 15.6 Selected Experiences and Reproductive and Sexual Behaviors among Ever-partnered Women Aged 15–49 Years by Whether They Had Been Physically or Sexually Abused by an Intimate Partner during Lifetime . 407 15.7.1 Percentage of Women Who Have Ever Been Forced to Have Sexual Intercourse Against Their Will and Their Relationship with the Perpetrator at the Time of the Forced Intercourse by Selected Characteristics. 408 15.7.2 Age at First Forced Sexual Intercourse among Women Aged 15–49 Years . 409 Page Table List of Figures xxxiii List of Figures 1.5 Number of Households in the Parish (Female Sample) and the 2001 Census . 12 2.1 Percent Distribution of Women Aged 15-49 Years . 18 2.2 Percent Distribution of Women Aged 15–49 Years by Partnership Status . 19 2.3 Percent Distribution of Women Aged 15–49 Years by Education Level (in Years) . 20 2.5 Percent Distribution of Women Aged 15–49 Years by Employment Status . 22 2.6 Percent Distribution of Women Aged 15–49 Years by Frequency of Church Attendance . 23 2.7 Percent Distribution of Women Aged 15–49 Years by Number of Children Born Alive . 24 3.1.1 Total Fertility Rates in Jamaica, 1975–2008 . 38 3.1.2 Age-Specific Fertility Rates for Seven Time Periods All Women Aged 15–49 Years: Jamaica 1975–2008 . 39 3.1.3 Two-Year-Period Age-Specific Fertility Rates by the Wealth Quintile of the Household . 40 3.3.1 Mean Age at First Menstrual Period by Age Cohort Jamaica, 1989–2008 . 42 3.3.2 Reported Sexual Experience among Young Women Aged 15–17 and 18–19 Years: Jamaica, 1993–2008 . 43 3.4.1 Percentage of Women Aged 20–49 Years Who Had Sexual Debut, First Union, and First Birth before Age 20 . 45 3.4.2 Median Age at First Sexual Experience and First Birth among Women Aged 15– 49 Years: Jamaica, 2002 and 2008 . 46 3.5.1 Current Sexual Activity by Current Relationship Status among Women Aged 15–49 Years: Jamaica, 1997–2008 . 47 3.5.2 Timing of the Last Sexual Intercourse among Young Adult Women and Men Aged 15–24 Years . 48 3.5.3 Trends in the Current Sexual Activity among Sexually Experienced Women and Men Aged 15–19 and 20–24 Years: Jamaica, 1997–2008 . 49 3.6.1 Trends in the Mean Duration of Postpartum Amenorrhea, Abstinence and Insusceptibility after the Most Recent Live Birth in the Last 24 Months among Women Aged 15–49 Years: Jamaica, 1997–2008 . 51 3.6.2 Opinions about the Ideal Duration of Breastfeeding among Women Aged 15– 49 Years: Jamaica, 1993–2008 . 53 3.7.1 Demographic Terminology for Pregnancy Intentions . 54 3.7.2 Planning Status of the Last Pregnancy among Women Aged 15–49 Who Were Currently Pregnant or Gave Birth in the Last 5 Years . 55 3.7.3 Trends in Planning Status of Last Pregnancy among Women Aged 15–49 Who Were Currently Pregnant or Gave Birth in the Last 5 Years Jamaica, 1989–2008 . 56 Page Figure xxxiv Reproductive Health Survey, Jamaica 2008 3.7.4 Planning Status of the Most Recent Pregnancy in the Last 5 Years by Maternal Age among Women Aged 15–49 Years . 56 3.7.5 Planning Status of the Last Pregnancy in the Last 5 Years by Number of Living Children . 57 3.8.1 Intention to Have No More Children by Number of Living Children among Sexually Experienced Women* Aged 15–49: Jamaica, 1997–2008 . 59 3.8.2 Timing of the Next Birth by Number of Living Children among Fertile Women Aged 15–49 Who Want More Children . 59 4.1.1 Percentage of Women Aged 15–49 Years Who Received No Prenatal Care Preceding Their Last Birth in the Last 5 Years by Selected Characteristics . 84 4.1.2 Initiation of Prenatal Care in the 1st Trimester among Women Aged 15–49 Who Gave Birth in 2003–2008 by Selected Characteristics . 85 4.1.3 Completion of 4 or More Prenatal Care Visits among Women Aged 15–49 Years Who Gave Birth in 2003–2008 by Selected Characteristics . 86 4.1.4 Adequacy of Prenatal Care among Women Aged 15–49 Years Who Gave Birth in 2003–2008: Jamaica, 1997–2008 . 87 4.1.5 Preventive Services Received by Women Aged 15–49 Years during Prenatal Care for Their Most Recent Pregnancies in the Last 5 Years Jamaica, 1997–2008. 89 4.1.6 Primary Location of Prenatal Care Visits for Women Aged 15–49 Years Who Gave Birth in 2003–2008: Jamaica, 2008 . 90 4.2 Percentage of Births in 2003–2008 Delivered by Cesarean Section by Selected Characteristics: Jamaica, 2008 . 91 4.4 Infant and Child Under 5 Mortality Rates—Live Births in 1998–2003 and 2003– 2008: Jamaica, 2008 . 94 5.1.1 Knowledge about Modern Contraceptive Methods among Women Aged 15–49 Years: Jamaica, 2008 . 108 5.1.2 Knowledge about Modern Contraceptive Methods among Women Aged 15–49 Years: Jamaica, 1989–2008 . 108 5.1.3 Knowledge about Modern Contraceptive Methods among Men Aged 15–24 Years: Jamaica, 2008 . 109 6.1.1 Trends in Ever-use of Contraception among All Women Aged 15–49 Years: Jamaica, 1989–2008 . 117 6.1.2 Trends in Ever-use of Various Contraceptive Methods among All Women Aged 15–49 Years: Jamaica, 1989–2008 . 118 6.2 Number of Living Children at the Time Women Aged 15–49 Years First Used a Contraceptive Method: Jamaica, 1997–2008 . 120 6.3.1 Trends in the Current Use of Contraception by Number of Children Born Alive among Women in Union Aged 15–49 Years: Jamaica, 1997–2008 . 121 6.3.2 Trends in Current Contraceptive Use of Selected Methods Women in Union Aged 15–49 Years: Jamaica, 1989–2008 . 122 6.3.3 Trends in Current Use of Contraception among All Women and Women in Union Relationships Aged 15–49 Years: Jamaica, 1997–2008 . 123 Page Figure List of Figures xxxv 6.4.1 Source of Supply for Modern Contraceptive Methods Among All Women Aged 15–49 Years Currently Using a Method . 125 6.4.2 Reported Availability of Public Family Planning Services “At Any Time” among All Women Aged 15–49 Who Obtain Contraception from Government Sources: Jamaica, 1989–2008 . 126 7.1.1 Trends in the Main Pill Brands Currently Used by Women Aged 15–49 Years: Jamaica, 1997–2008 . 164 7.1.2 Opinions Regarding the Effectiveness of the Pill among Women Aged 15–49 Years by Years of Education: Jamaica, 2008 . 165 7.2 Awareness and Ever Use of the Emergency Hormonal Contraception among Women Aged 15–49 Years: Jamaica, 2002–2008 . 166 9.1.1 Contraceptive Prevalence and Sterilization Prevalence among Women in Union Aged 15–49 Years: Jamaica, 1993–2008 . 197 9.1.2 Trends in the Age at Sterilization Procedure Women in Union Aged 15–44 Years: Jamaica, 1989–2008 . 199 9.1.3 Mean Number of Children by Current Age among Sterilized and Non-sterilized Women in Union Aged 15–49 Years: Jamaica, 2008 . 200 9.2 Trends in Sterilization Regrets among Sterilized Women Aged 15–49 Years: Jamaica, 1993–2008 . 201 9.3 Trends in the Intention to Use Female Sterilization by Future Fertility Preferences Fecund Women Aged 15–49 Years: Jamaica, 1993–2008 . 202 9.4 Reasons for Not Wanting to Use Contraceptive Sterilization by Fertility Preferences among Women Aged 15–49: Jamaica, 2008 . 203 10.1.1 Most Commonly Cited Reasons for Not Currently Using Contraception, by Current Relationship Status among All Women Aged 15–49 Years: Jamaica, 2008. 214 10.1.2 Desire to Use a Different Contraceptive Method, by Current Method among Women Aged 15–49 Years Who Are Currently Using Contraceptives: Jamaica, 1997–2008 . 215 10.2.1 Unmet Need for Family Planning among All Women Aged 15–44 Years: Jamaica, 2008 . 216 10.2.2 Trends in Unmet Need for Family Planning among All Women Aged 15–44 Years: Jamaica, 1993–2008 . 217 11.1 Trends in Preventive Reproductive Health Practices among Women Aged 15–49 Years: Jamaica, 1997–2008 . 224 11.2 Most Commonly Cited Reasons for Never Having Had a Cervical Cancer Screening Test among Women Aged 15–49 Years . 225 11.5.1 Lifetime and Current Smoking Prevalence Rates by Age Group among Women Aged 15–49 Years . 228 11.5.2 Drinking Prevalence Rates among Young Women and Men Aged 15–24 Years: Jamaica, 2008 . 229 Page Figure xxxvi Reproductive Health Survey, Jamaica 2008 11.5.3 Reported Drug Use during the last 12 Months among Young Women and Men Aged 15–24 Years: Jamaica, 2008 . 230 12.1 Union Relationship Status among Young Women and Men Aged 15–24 Years: Jamaica, 2008 . 242 12.2 Trends in Sexual Experience among Young Women and Men Aged 15–19 and 20–24 Years: Jamaica, 2008 . 243 12.3.1 Percentage of Young Adult Women and Men Who Became Sexually Experienced before Given Ages: Jamaica, 2008 . 244 12.3.2 Trends in Mean Age at First Sexual Experience among Young Women and Men Aged 15–24 Years: Jamaica, 1993–2008 . 245 12.3.3 Age Difference Between Partners at First Sexual Experience among Young Women and Men: Jamaica, 2008 . 246 12.3.4 Relationship with the First Sexual Partner among Young Women and Men Aged 15–24 Who Reported Coerced First Sexual Experience . 247 12.4.1 Contraceptive Use at the First Sexual Experience among Young Women Aged 15–24 Years: Jamaica, 1993–2008 . 248 12.4.2 Contraceptive Use at the First Sexual Experience among Young Men Aged 15– 24 Years: Jamaica, 1993–2008 . 249 12.4.3 Main Reasons for Not Using Contraception at First Sexual Experience among Young Women and Men Aged 15–24 Years: Jamaica, 2008 . 250 12.5.1 Use of Contraceptives at the Last Intercourse in the Last 30 Days among Young Women Aged 15–24 Years: Jamaica 1993–2008 . 251 12.5.2 Use of Contraceptives at the Last Intercourse in the Last 30 Days among Young Men Aged 15–24 Years: Jamaica 1993–2008. 252 12.5.3 Number of Sexual Partners During the Last 12 Months and Lifetime among Young Women and Men Aged 15–24 Years: Jamaica, 2008 . 253 12.6 Discussions with a Parent or Guardian of Specific FLE Topics before Reaching Age 18 Reported by Young Women and Men Aged 15–24 . 255 12.7.1 Trends in Prevalence of Sex Education in School by Specific Topic among Young Women Aged 15–24 Years Jamaica 1993–2008 . 257 12.7.2 Trends in Prevalence of Sex Education in School by Specific Topic among Young Men Aged 15–24 Years Jamaica 1993–2008 . 257 12.8.1 Preferred Source of Information about Family Life Education among Women and Men Aged 15–24 Years: Jamaica, 2008 . 258 12.8.2 Exposure to FLE Messages through Various Media Programs Reported by Young Women and Men Aged 15–24: Jamaica, 2008 . 259 12.8.3 Behavior-change after Exposure to FLE Messages through Various Media Programs Reported by Young Women and Men Aged 15–24 . 260 12.10 Comprehensive Knowledge of HIV among Young Women and Men Aged 15–24 Years, by Type of Question: Jamaica, 2008 . 264 13.2 Principal Source of Information about STIs among Women and Men Aged 15– 24 Years Reproductive Health Survey: Jamaica, 2008 . 317 Page Figure List of Figures xxxvii 13.3 Recent Experience of Selected STIs Symptoms among Women and Men Aged 15–24 Years Reproductive Health Survey: Jamaica, 2008 . 318 13.4 Risky Sexual Behaviors among Women and Men Aged 15–24 Years Who Had Sexual Intercourse in the Last 12 Months Reproductive Health Survey: Jamaica, 2008. 320 14.1.1 Awareness and Knowledge of HIV/AIDS: Women Aged 15–49 Years and Young Men 15–24 Years: Jamaica, 2008 . 337 14.1.2 Correct Knowledge of MTCT among Women Aged 15–49 Years and Young Men Aged 15–24 Years: Jamaica, 2008 . 338 14.1.3 Spontaneously Named Methods of Preventing HIV Transmission Women Aged 15–49 Years: Jamaica, 2008 . 339 14.1.4 Spontaneously Named Methods of Preventing HIV Transmission Young Men Aged 15–24 Years: Jamaica, 2008 . 340 14.2.1 Knowledge and Experience of HIV Testing Among Women 15–49 Years of Age: Jamaica, 2008 . 341 14.2.2 Knowledge and Experience of HIV Testing Among Young Men 15–24 Years of Age: Jamaica, 2008 . 342 14.2.3 Place of Last HIV Test for Women Aged 15–49 Years Who Reported Ever Being Tested for HIV/AIDS: Jamaica, 2008 . 343 14.3.1 Perceived Risk of Getting HIV/AIDS Among Women Aged 15–49 Years, by Marital Status: Jamaica, 2008 . 344 14.3.2 Accepting Attitudes toward Persons Living with HIV/AIDS among Women Aged 15–49 Years and Young Men Aged 15–24 Years . 345 15.1.1 Agreement with Various Statements about Gender Roles among Young Adult Women and Men Aged 15–24 Years: Jamaica, 2008 . 370 15.1.2 Agreement That a Husband Is Justified in Beating His Wife under Certain Circumstances among Young Adult Women and Men: Jamaica, 2008 . 371 15.2 Percentage of Young Adult Women and Men Who Reported Various Acts of Psychological and Physical Punishment Used to Discipline the Children in Their Households: Jamaica, 2008 . 373 15.3.1 Experience of Parental Physical Abuse before Age 15 by History of Witnessing Physical Abuse between Parents Young Adult Women and Men Aged 15–24 Years: Jamaica, 2008 . 375 15.3.2 Agreement That Physical Punishment Is Necessary to Raise Children Well by History of Witnessing or Experiencing Parental Physical Abuse among Women Aged 15–49 Years: Jamaica, 2008 . 375 15.4.1 Experience of Controlling Behaviors from a Current or Former Spouse or Partner among Ever-Partnered Women Aged 15–49 Years: Jamaica, 2008 . 376 15.4.2 Controlling Behaviors Towards a Current or Former Spouse or Partner Reported by Ever-Partnered Men Aged 15–24 Years: Jamaica, 2008 . 377 Page Figure xxxviii Reproductive Health Survey, Jamaica 2008 15.4.3 Reported Lifetime and Recent (Last 12 Months) Intimate Partner Violence (IPV) by Type of Violence among Ever-partnered Women Aged 15–49 Years: Jamaica, 2008 . 378 15.4.4 Reported Lifetime and Recent IPV among Ever-Partnered Young Women and Men Aged 15–24 Years: Jamaica, 2008 . 380 15.5.1 Coping Patterns among Ever-partnered Women Aged 15–49 Years Who Reported Recent Physical or Sexual Abuse: Jamaica, 2008 . 381 15.5.2 Levels of Help-Seeking from an Institution by Source of Help Ever-partnered Women Aged 15–49 Years Who Reported Recent Physical or Sexual Abuse . 382 15.5.3 Most Commonly Cited Reasons for Not Seeking Institutional Help among Ever- partnered Women Aged 15–49 Years Who Reported Recent Physical or Sexual Abuse: Jamaica, 2008 . 383 15.6.1 Selected Experiences among Ever-partnered Women Aged 15–49 with or without Physical or Sexual IPV during Lifetime: Jamaica, 2008 . 384 15.6.2 Knowledge, Attitudes and Experiences Related to HIV Transmission among Ever-partnered Women Aged 15–49 Years with or without Physical or Sexual IPV during Lifetime: Jamaica, 2008 . 385 15.7.1 Percentage of Women Aged 15–49 Years Who Have Ever Been Forced to Have Sexual Intercourse Against Their Will by Selected Characteristics . 386 15.7.2 Percentage of Women Aged 15–49 Years Who Have Ever Been Forced to Have Sexual Intercourse Against Their Will by Age at First Forced Intercourse: Jamaica, 2008 . 387 Page Figure Chapter 1: Background 1 Chapter 1 Background Jamaica has a well-established family planning program, which has been offering contraceptive services through a national program since the late 1960s. There is strong government support for family planning, which increased after the worldwide adoption of the Programme of Action of the 1994 International Conference on Population and Development (ICPD). Contraceptive policy-making is mainly the responsibility of the National Family Planning Board (NFPB) and the Ministry of Health. NFPB is a statutory board established in 1970 as the principal governmental agency responsible for preparing, carrying out, and promoting family planning and population programs in Jamaica. Since the mid 1970s, the United States Agency for International Development (USAID) has worked with the NFPB to increase access to family planning services, primarily through: promotion of quality client-centered family planning and reproductive health policies and programs; improvements in contraceptive logistic management, forecasting and procurement procedures; training; organization of mass media and public information campaigns; and monitoring and evaluating program effectiveness and sustainability. Understanding trends in contraceptive prevalence overall and in the use of specific contraceptive methods is equally important for health planners and family planning program managers as it is for donors involved in providing contraceptive commodities and assistance in all the aspects needed to support these programs. 1.1 Historical, Geographical, and Demographic Background Jamaica is one of the islands in the Caribbean archipelago. It is located in the northwestern section and is one of the four islands that comprise the Greater Antilles. It is situated at latitude 18 north and longitude 77 west and is approximately 145 kilometres south of Cuba and 161 kilometres west of Haiti. It is English-speaking and shares 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 countries included in the Latin American and Caribbean Region; and at the wider level, is a member of the United Nations and its affiliate organizations. Jamaica itself has a maximum length of 235 kilometres and widths varying from 35 to 82 kilometres, with a total area of 4,244 square miles or 10,991 square kilometres. It is divided into three counties - Cornwall in the west, Middlesex in the center and Surrey in the east. There are 2 Reproductive Health Survey, Jamaica 2008 fourteen parishes: Trelawny, St. James, Hanover, Westmoreland and St. Elizabeth in the county of Cornwall; St. Mary, St. Ann, Manchester, Clarendon and St. Catherine in the county of Middlesex; and Kingston, St. Andrew, St. Thomas and Portland in the county of Surrey. Other administrative divisions have been defined and used for many purposes, the most important being the breakdown into constituencies, defined by law, which form the political divisions of the country. However, the most significant administrative division for this study is the breakdown into health regions. The composition of the health regions have varied from time to time. The current divisions comprise the following grouping of parishes and these are used in this study:  Health Region 1 Kingston, St. Andrew, St. Thomas and St. Catherine  Health Region 2 Portland, St. Mary and St. Ann  Health Region 3 Trelawny, St. James, Hanover and Westmoreland  Health Region 4 St. Elizabeth, Manchester and Clarendon The population of Jamaica at the end of 2008 was 2,692,358 and the annual growth rate was 0.8 percent. The crude birth rate (per 1000 mean population) was 20, with a crude death rate of 6; the rate of natural increase was accordingly 14.38 per 1000 mean population. The natural rate of growth of the population has been falling over recent years. Both the birth and death rates have been declining but at different rates. In 1861, the birth rate was 39.6 per 1000 mean population with a death rate of 32.2. By 1970, the birth rate was still in the high 30s (39.1) but it fell more rapidly in the 1970s and 1980s. In 1982 it was at 30.9 and by 1991 it had fallen to 25.1. The movement in the death rate was more dramatic. By 1970, it had fallen to 8.2. Since then, the decline in birth rates has been more significant than in death rates. The distribution of the population over the period covered by the four earlier contraceptive prevalence and reproductive health surveys (1992, 1996, 2001, and 2008), although not equal in proportion, has remained fairly consistent as may be seen in Table 1.1.1 below: Health Region 1992 1996 2001 2008 1 46.6 46.8 46.5 46.8 2 14.0 13.9 14.1 13.7 3 17.6 17.5 17.6 17.6 4 21.8 21.8 21.8 21.9 Total 100.0 100.0 100.0 100.0 Table 1.1.1 Distribution of the Population by Health Region In 1992, 1996, 2001 and 2008 (Percent Distribution) Source: Demographic Statistics 2009, Statistical Institute of Jamaica. Chapter 1: Background 3 Age distribution is important to any study of fertility, contraceptive behavior and reproductive health. Of particular significance is the proportion of women of childbearing age. Also of importance is the proportion of young adults, both male and female, in the population. In general, the population under 15 years of age has been identified as the infant and child population, the population between 15 and 24 as the young adult population and the female population between the ages of 15 and 49 as those in the childbearing years. Thus, demographic inquiries and, in particular, contraceptive prevalence and reproductive health surveys have focused on breakdowns of the population into these broad age groupings. Table 1.1.2 below presents breakdowns of the male and female population at the end of the years preceding the last 4 surveys. Age Group 1992 1996 2001 2008 1992 1996 2001 2008 0–4 11.7 11.3 10.8 10.8 11.0 10.6 10.8 10.1 5–14 23.7 23.1 22.5 22.5 22.5 21.9 22.5 21.3 15–24 20.2 19.1 18.0 18.0 20.0 19.0 18.1 17.9 25–34 15.2 15.1 15.0 15.1 16.1 16.0 15.0 16.0 35–49 13.9 15.5 17.2 17.1 13.9 15.7 17.1 17.7 50 or more 15.3 15.8 16.5 16.4 16.5 16.8 16.5 17.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Source: Demographic Statistics 2009, Statistical Institute of Jamaica. Table 1.1.2 Age Distribution of the Total Population End of the Year 1992, 1996, 2001, and 2008 (Percent Distribution) Males Females Type of Urban Area 1970 1982 1991 2001 2008 † Kingston Metropolitan Area 29.6 26.8 26.3 25.0 24.7 Other urban areas 14.4 22.6 25.1 29.7 30.1 Percentage of the population in urban areas 44.0 49.4 51.4 54.7 54.8 Source: Reports of the 1970, 1982, 1991, 2001 Population Censuses, and 2008 Census projections, the Statistical Institute of Jamaica. Table 1.1.3 Percentage of the Population in Urban Areas * End of the Year 1970, 1982, 1991, 2001, and 2008 Percentage of the Population and Census Year * Urban areas as defined for purpose of each census. † 2001 census projections. 4 Reproductive Health Survey, Jamaica 2008 Another important factor is the distinction between urban and rural areas. As a reflection of socioeconomic development, the population of Jamaica has gradually shifted from being more rural in 1970 to being more urban in the early 1990s (Table 1.1.3). It is generally recognized that residential location can have an impact on quality of life and access to services, and accordingly can exert a strong influence on attitudes and behaviors. 1.2 Population Policies and Programs Jamaica, along with other members of the international community, has experienced the intensification of pressures of high population growth on available resources within their countries and the constraints which this has placed on social and economic progress. Growing disparities in social benefits point to a real need for adopting a strategy of planned population programs aimed at reducing the rate of growth of the population within a policy of continued improvement in the welfare of the people. An important aspect of pursuing such a policy is the requirement for making assessments at frequent intervals of the demographic behaviors of the people. Thus, it is necessary to measure fertility and mortality, as well as other related phenomena, at specific periods of development. Fertility levels are directly determined by a series of events which, either as a matter of individual choice or indirectly through socio-cultural practices, interfere with the biological determinants. In studying fertility levels and trends in Jamaica, it is important to consider the complex family formation patterns. Unlike other areas of the world, family formation in the Caribbean region has very distinct characteristics, which prevent the use of simple marital-nonmarital differentials in studying fertility and contraceptive needs. Generally, women first enter a sexual union in which they do not share a household with their partners; this is known as a visiting union. Often, this is followed by a common-law union, in which couples do share a household but are not legally married. However, women and men may move from common-law unions to visiting unions and from either type of union directly into legal marriage. Since some women and men are involved in several types of unions in varying sequences during their reproductive lives, their exposure to the risk of pregnancy and need of contraception to prevent an unintended pregnancy varies much more than for couples in other countries with more formal union patterns. A conceptual framework for the study of fertility patterns generally takes into account several important inter-related contributors. One is the proportion of the female population of reproductive age who live in stable unions such as formal marriages and consensual unions. Another is adoption of fertility control measures: contraception (defined as any deliberate practice, including abstinence and sterilization, undertaken to reduce or eliminate the risk of conception) and induced abortion. At a third level, there are two important behavioral variables that can affect fertility: frequency and duration of breastfeeding, and coital frequency. In Chapter 1: Background 5 addition, any study of fertility must take account of associated socio-economic, cultural, and environmental influences which affect its level and movement, identifying factors which impact on these measurements. Substantial improvements in women’s reproductive health and achievement of desired fertility will depend not only on further increases in contraceptive use, but also on improvements in method selection and on reductions in contraceptive discontinuation and failure rates. Education and health promotion efforts have targeted the lack of awareness among women about other important reproductive health topics: the need for preventive medical care before and after a birth; follow-up care after an abortion; ways to prevent STIs and HIV; and where and when to go for other preventive health services. Special emphasis has been placed on meeting the reproductive health needs of Jamaican young adults. Recent programs have targeted the promotion of safer sex practices through information, education and communication (IEC) messages and condom programming, using mass-media, clinic-based, and peer-education approaches. While there have been significant increases in the life expectancy of the population, there are certain areas -- such as infant and child mortality -- where existing levels are still above acceptable standards. A proper assessment of the extent of the problem becomes difficult since recent studies have confirmed possible inaccuracies in the official estimates, which are of concern to health administrators. The concerns identified above are reflected in the proposed program of work covered in the 2008 Reproductive Health Survey (RHS) as set out in the identified objectives and scope of work, a continuation of the work programs of the earlier RHSs and still earlier Contraceptive Prevalence Surveys. Thus, the 2008 RHS is part of the continuing series of periodic inquiries undertaken in Jamaica, aimed at providing information on fertility levels and related factors which affect contraceptive use, unintended pregnancies and reproductive health. In addition, the 2008 survey collected for the first time comprehensive data on HIV and on gender-based violence. 1.3 Survey Objectives Population-based surveys of women of childbearing age using national representative samples are considered to be the best and most timely way to collect information on such topics as fertility, planning status of pregnancies, family planning, health behaviors and use of women’s health services, contraceptive knowledge and attitudes, knowledge about AIDS transmission and prevention, and other reproductive health issues. These surveys not only represent a valuable source of up-to-date information to evaluate programs and develop program strategies, but also provide baseline information for future studies. To identify reproductive health needs and evaluate the impact of the national family planning and maternal and child health programs, periodic sample surveys have been used in Jamaica since the mid-1970s—in 1975, as part of the World Fertility Survey project; in 1983, 1989, and 1993, as Contraceptive Prevalence Surveys; and in 1993, 1997, 2002 and 2008 as Reproductive Health Surveys. The RHS project uses 6 Reproductive Health Survey, Jamaica 2008 scientific sampling to collect a comparative body of nationally representative information on population, nutrition, and health issues. RHS employs large nationally representative samples of women and men and, by asking the same questions to both, allows for estimation of comparable gender indicators. By collecting data every 5 years, RHS documents the “intermediate variables” related to fertility and reproductive health in Jamaica and tracks changes over time. A principal objective of the 2008 RHS has been to examine aspects of reproductive health status and needs that can be used to help direct or modify program interventions. The survey looks at the trends and levels of contraceptive use, at method selection, and to what extent family planning methods are being used effectively (contraceptive failure and continuation rates). In addition, it provides data on women’s knowledge, opinions, and attitudes toward practices related to family planning, fertility, women’s health, and sexually transmitted diseases, including HIV prevention. It also aims to assess other factors which may affect reproductive behaviors, including risk factors for unintended pregnancy, so that program interventions may be improved. These data are particularly useful in assisting policy makers and health planners to assess health services needs, to identify reproductive health behaviors associated with poor health outcomes, and to design better programs targeted to meeting the needs of key population subgroups. In the aftermath of the objectives set out at the ICPD in 1994, most countries started to reform their family planning and reproductive health programmes, particularly in the area of family planning and adolescent reproductive health, in order to re-align them to the principles of the Cairo Programme of Action. The Programme of Action recommended that programmes should have the dual goal of covering all the reproductive health needs of their clients and promoting gender equity. For the first time, the 2008 RHS collected population-based information on gender norms and gender-based violence (GBV) at a national level. It had been widely recognized that GBV occurs in all cultures; it is usually perpetrated by men against their female partners; and it affects women of all ages and all socio-economic and educational backgrounds. Gender stereotypes, women’s economic dependence on men, cultural acceptability, loose or nonexistent legislation to protect women’s fundamental human rights, and lack of preventive measures for victims are some of the known factors that contribute to intimate partner violence. Since domestic violence affects women’s physical, sexual, psychological, economical, and social well being, it implicitly affects women’s health, including their reproductive health. Studies have shown that women subjected to domestic violence may be unable to use contraception effectively and consistently, and may lack control or negotiation skills that will enable them to avoid unintended pregnancies and sexually transmitted diseases, including HIV/AIDS. High quality data on gender and GBV is critical to identify risk groups, document risk factors, track trends over time, and determine the impact of policies and interventions. Chapter 1: Background 7 To achieve further reductions of maternal and infant mortality and morbidity, rates of unintended pregnancy, risk of STI infection, and the level of gender-based violence, the government of Jamaica is committed to increasing its investments in health, particularly in the area of health education and prevention. Such efforts are particularly aimed at high risk groups, such as young adults, rural residents, economically disadvantaged populations, and victims of gender-based violence. Similar to the Jamaican government, the United States Agency for International Development (USAID) has set two main goals in its work in the area of population, health, and nutrition: to stabilize population growth, and to improve the health of the population. To attain these goals, USAID has several strategic objectives that are addressed by the RHS project: a) to reduce unintended pregnancies; b) to reduce maternal morbidity and mortality; c) to reduce infant and child mortality; d) and to reduce STD/HIV transmission. Starting in the early 2000s, USAID, NFPB and their partners have pooled their efforts to strengthen sex education programmes in the country, using school-based, clinic-based, or peer-education and mentoring approaches. All these efforts need to be evaluated, reviewed and refocused, in accordance with the documentation of program achievements and gaps and identification of new challenges and needs. The RHS project is a collection of important demographic and reproductive health indicators. These indicators are used to examine health trends and set targets for improvement, allocate resources, and monitor performance of reproductive health programs. Their collection aims to address the needs of the NFPB and other governmental institutions, local and international non-governmental organizations, and bilateral and multilateral donors in achieving several long-term and immediate objectives:  to assess the current situation in Jamaica concerning fertility, unintended pregnancies, contraception, sexual behaviors, and various other reproductive health issues;  to assess knowledge, attitudes, use, and source of contraception, including a special module that provides estimates of contraceptive continuation and failure rates;  to document changes in fertility and contraceptive prevalence rates and study factors that affect these changes, such as geographic and socio-demographic factors, reproductive norms, and access to and availability of family planning services;  to assess health risk behaviors and utilization of preventive health services;  to enable policy makers, program managers, and researchers to evaluate and improve existing programs and to develop new strategies (a good example is use of RHS data to evaluate the JASTYLE project aimed at sex education and health promotion programs for youths); 8 Reproductive Health Survey, Jamaica 2008  to obtain data about knowledge, attitudes, and behavior of young adults 15–24 years of age, including teen pregnancy and its risk factors;  to provide data on the level of knowledge about transmission and prevention of HIV;  to document gender norms and prevalence of gender-based violence, identify risk factors, and examine correlates with other reproductive health issues;  to identify subgroups at high risk for adverse reproductive health outcomes and obtain the data needed to develop targeted interventions; differentials in reproductive behaviors and outcomes were examined across parishes and health regions and by other socio-demographic characteristics in order to assess program impact and indicate who might benefit from special interventions and program effort. A secondary objective of the survey has been to enhance the capabilities of scientists from STATIN and other Jamaican agencies to process, analyze, and interpret reproductive health data. The RHS project has a strong capacity-building orientation, aimed at achieving self-sufficiency at the country level, especially as an increasing number of countries are graduating from the need of USAID health and population assistance. As such, the RHS 2008 included a one-week data analyses workshop implemented shortly after the conclusion of the data collection and processing. The general objective of the workshop was to increase access to the RHS data (current and previous cycles) and enhance application and diffusion of the survey results among groups of technical people in the health and the social sector. This in turn was viewed as an essential step in the construction of processes that generate information specific to population and reproductive health activities and in strengthening the capacity of participant organizations to apply data in policy formulation, and in the design, execution and evaluation of projects and programs. 1.4 Institutional Participation Similar to previous RHSs, the NFPB contracted the survey implementation to be executed by the Statistical Institute of Jamaica (STATIN), with technical assistance from the Centers for Disease Control and Prevention, Division of Reproductive Health (CDC/DRH). This activity follows participation of the CDC/DRH in previous national family planning and reproductive health surveys in 1989, 1993, 1997, and 2002 conducted by the NFPB in Jamaica. Technical assistance for the CDC/DRH activities was funded by USAID/Jamaica, through the Participating Agency Program Agreement (PAPA) between the United States Agency for International Development/Bureau for Global Health/Office of Population and Reproductive Health (USAID/GH/PRH) and CDC/DRH. The STATIN team was responsible for designing the sample and updating the sampling frame, providing training facilities, recruiting interviewers and supervisors to carry out survey activities, Chapter 1: Background 9 conducting the fieldwork, data entry and data cleaning, data analyses, and preparing reports on specific topics (i.e. a young adult report and four health-region specific reports). CDC/DRH was responsible for questionnaire development, data-entry set up, training and training materials, technical input to field testing and field work, as well as data cleaning and management, preparation of the survey data sets, and writing of the final survey report. It was also responsible for a one-week data analyses workshop, organized in Kingston, January 2010, with USAID and NFPB support. The NFPB staff provided ongoing oversight for all aspects of the survey, including the data analysis workshop. Data collection for the RHS was carried out by approximately 100 female and male interviewers, with female interviewers conducting interviews of females and males and men interviewers collecting information from male respondents only. Most of the interviewers and supervisors had experience conducting interviews in other household surveys, including the three previous national Reproductive Health Surveys. Interviewer training and fieldwork was managed by staff of the STATIN, with the involvement of Dr. Douglas Forbes and Ms. Natalee Simpson, STATIN survey director and project manager, respectively; Ms. Merville Anderson, director of the field work and operation activities; and Ms. Avery Gaynor, data entry supervisor and CSPro expert; and the Centers for Disease Control and Prevention team (Dr. Florina Serbanescu, medical epidemiologist and CDC principal investigator; Danielle Jackson Suchdev, health scientist and co- principal investigator; Alicia Ruiz and Fernando Carlosama, program analysts; Dr. Paul Stupp, demographer; and Dr. Reina Turcios-Ruiz, medical epidemiologist). Interviewer training was done jointly by STATIN and CDC and took place in Kingston and Ocho Rios, just before data collection began. It consisted of one week of classroom training in fieldwork procedures and proper administration of the questionnaire, and one week of practical training in the field with close monitoring by the trainers. Fieldwork lasted from June 2008 through April 2009, with field work interrupted between December and February. Interviews were conducted at the homes of respondents and lasted an average of 47 minutes for women and 46 minutes for men. Completed questionnaires were reviewed in the field by team supervisors, and then taken to the STATIN headquarters for data processing. The questionnaire was designed to collect information on the following:  Demographic characteristics  Household assets (durable goods and dwelling characteristics)  Fertility and child mortality  Family planning and reproductive preferences  Reproductive and maternal health care utilization  Preventive and curative health care utilization  Risky health behaviors (smoking, alcohol and drug use)  Young adult health education and behaviors 10 Reproductive Health Survey, Jamaica 2008  Gender norms and gender-based violence  HIV/AIDS and other STIs 1.5 Sampling Design Similar to previous surveys, the Jamaica RHS 2008 was a population-based probability survey consisting of in-person, face-to-face interviews with women (15–49 years) and men (15–24 years) at their homes. The survey was designed to collect information from a representative sample of approximately 8,200 women of reproductive age and 2,500 young adult men throughout Jamaica. The universe from which the respondents were selected included all females between the ages of 15 and 49 years and all males aged 15–24 years, regardless of marital status, who were living in households in Jamaica when the survey was carried out. The female and male samples were selected independently. The household survey employed a stratified multistage sampling design using the 2001 census as the sampling frame. The household selection for the male sample was independent from the selection of households for the female sample. To better assist the key stakeholders in assessing the baseline situation at a sub-national level, the female sample was designed to produce estimates for all of the 14 parishes and the 4 health regions in Jamaica. The smaller male sample was designed to produce sub-national estimates for health regions only. The samples for both women and men are also designed to produce estimates for urban and rural populations at the national level. The first stage of the three-stage sample design was the selection of census sectors, also known as Enumeration Districts (EDs). The 14 parishes of Jamaica are further subdivided into 307 “sampling regions” of approximately equal size, which constitute the strata for the JRHS sample. Within each sampling region 2, 3 or 4 EDs were selected with probability proportional to the size (PPS) of the ED, which is measured by the number of households in the ED, according to the 2001 census. All 307 sampling regions are represented in the male and female samples. The number of sampling regions in a parish varies as a function of population size and ranges from 14–22 in the smaller parishes—14 in Trelawny, Hanover, Westmorland, and St. Elizabeth, 15 in St. Ann, 16 in Portland, 17 in St James, 18 in Manchester, 20 in Kingston and St. Thomas, 22 in Clarendon and St. Mary—to a high of 46 in St. Catherine and 50 in St. Andrew. In the first stage selection, a total of 628 EDs were selected as primary sampling units (PSUs), as shown in Table 1.5. The target number of completed interviews in each sample (8,200 and 2,500, respectively for females and males) was divided among the 14 parishes and the minimum acceptable number of interviews per parish was set at 500 for the female sample and 176 for the male sample, equally distributed among the sampling regions within each parish. The average number of women aged 15–49 years and men 15–24 years per household identified in the 2002 Jamaica Reproductive Health Survey was used to provide an estimate of the number of households to be Chapter 1: Background 11 Kingston 28,200 40 1,510 18.7 St. Andrew 164,513 110 1,540 106.8 St. Thomas 28,210 40 1,267 22.3 Portland 23,916 36 1,292 18.5 St. Mary 32,167 48 1,200 26.8 St. Ann 45,378 30 1,410 32.2 Trelawny 21,733 31 1,079 20.1 St. James 49,741 34 1,533 32.4 Hanover 20,283 31 1,311 15.5 Westmoreland 42,029 28 1,447 29.1 St. Elizabeth 41,687 28 1,207 34.5 Manchester 51,425 36 1,433 35.9 Clarendon 64,669 44 1,472 43.9 St. Catherine 134,378 92 1,144 117.4 Total 748,329 628 18,845 39.7 Kingston 28,200 40 1,220 23.1 St. Andrew 164,513 110 1,428 115.2 St. Thomas 28,210 40 1,312 21.5 Portland 23,916 36 993 24.1 St. Mary 32,167 48 1,023 31.4 St. Ann 45,378 30 917 49.5 Trelawny 21,733 32 985 22.1 St. James 49,741 34 1,004 49.6 Hanover 20,283 30 738 27.5 Westmoreland 42,029 28 952 44.1 St. Elizabeth 41,687 28 969 43.0 Manchester 51,425 36 906 56.8 Clarendon 64,669 44 1,124 57.5 St. Catherine 134,378 92 1,157 116.1 Total 748,329 628 14,727 50.8 Female Sample Male Sample HH = households; PSU = primary sampling unit. Table 1.5 Number of Households (HH) in the Jamaica RHS08 Sample and the 2001 Census and the Ratio of the Number of Households in the Census to the Number of Households in the Sample, by Parish Reproductive Health Survey: Jamaica, 2008 Parish No. of HH in Census No. of PSUs in the Sample No. of HH Sampled Ratio of HH-Census to the HH in Sample 12 Reproductive Health Survey, Jamaica 2008 1,200 1,144 1,4721,433 1,207 1,447 1,311 1,079 1,410 1,5331,5101,540 1,267 1,292 64,669 134,378 51,425 49,741 21,733 20,283 42,029 32,167 45,378 41,687 23,916 28,210 164,513 28,200 0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 Ki ng sto n St . A nd re w St . T ho m as Po rtla nd St . M ar y St . A nn Tr ela wn y St . J am es Ha no ve r W es tm or ela nd St . E liz ab eth M an ch es ter Cl ar en do n St . C ath er ine H o u se h o ld s in S a m p le -30,000 20,000 70,000 120,000 170,000 220,000 270,000 320,000 H o u se h o ld s in C e n su s Female Sample Census(2001) Figure 1.5 Number of Households in the Parish (Female Sample) and the 2001 Census visited in each parish to produce the required number of completed female and male interviews in each parish. With these criteria, the number of dwellings to be interviewed in each PSU was generally equal within each parish but varied between parishes. Figure 1.5 compares the distribution of households in the female sample (shown with bars) and the distribution of households in the 2001 Census (line graph) by the 14 parishes. The sampling fraction ranges from 1 in 16 households in the Hanover (the least populated parish) to 1 in 117 in St. Catherine. Similarly, the sampling fraction in the male sample ranges from 1 in 22 in St. Thomas to 1 in 116 in St. Catherine. Given that the overall ratio of households in the census to households in the female sample is 39.8 (and 50.8 for men), if the ratio of households (HH) in the census to the households in the sample is above 39.8 (50.8 for men) then the parish has been under-sampled, and if the ratio is less than 39.8 (50.8 for men) then the parish has been over-sampled. After the first stage selection of 628 PSUs (Enumeration Districts), each selected PSU was relisted to obtain an updated count of households in that PSU. In the second stage of sampling, clusters of households were randomly selected within each PSU chosen in the first stage. Separate households were selected for male and female interviews. Determination of the cluster sizes was based on the number of households required to obtain the target average number of completed interviews per cluster in each parish. The total number of households selected in each cluster took into account information from the 2002 RHS on the proportions of unoccupied households, households with women aged 15–49 years (and men aged 15–24 years per household in the male sample), and an expected response rate of 95%. Chapter 1: Background 13 Finally for the third stage of sampling, in each of the households selected in the female sample, one woman between the ages of 15 and 49 was selected at random for interview (if there was more than one woman in the household). Likewise, in the male sample, one man between the ages of 15 and 24 was selected at random for interview. Because the survey collected information from a representative sample of women aged 15–49 years and males aged 15–24 years, the data can be used to estimate percents, averages, and other measures for the entire population of women of reproductive age and young adult males residing in Jamaican households in 2008. Kingston Metropolitan Area Other Urban Rural 1 2 3 4 Household visits Identified eligible respondent 45.3 43.1 46.2 45.5 44.6 46.4 44.5 46.5 No eligible respondent 34.1 32.2 30.6 36.4 31.4 35.4 35.7 34.5 Occupant not at Home 2.8 2.9 3.1 2.6 2.9 2.8 2.8 2.7 Household refusal 1.6 2.7 2.3 0.9 2.2 0.5 1.4 2.0 Unoccupied household 6.2 3.8 7.0 6.5 5.3 6.0 6.2 7.5 Other 9.9 15.3 10.8 8.1 13.7 8.7 9.4 6.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of households visited 18,841 2,867 5,162 10,812 5,460 3,905 5,364 4,112 Eligible women (15–49) Completed interviews 96.7 96.9 95.7 97.1 96.2 97.2 97.0 96.5 Eligible absent 2.5 2.1 3.4 2.2 3.2 2.1 2.2 2.4 Eligible refusal 0.8 1.0 0.9 0.7 0.7 0.7 0.8 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of eligible women identified 8,542 1,236 2,385 4,921 2,433 1,812 2,385 1,912 No. of completed interviews 8,259 1,198 2,283 4,778 2,340 1,761 2,313 1,845 Table 1.6A Results of Household Visits and Individual Interview Status of Eligible Women Aged 15–49 Years by Residence and Health Region (Percent Distribution) Household Visits and Eligibility Total Residence Health Region 1.6 Response Rates Of the 18,841 households selected in the female sample and 14,729 households selected in the male sample, 8,542 and 2,941 included at least one eligible respondent (a woman aged 15–49 years or a man aged 15–24 years). Of these, 8,259 women and 2,775 men were successfully interviewed, yielding response rates of 96.7% and 94.4%, respectively (Tables 1.6A and 1.6B). As 14 Reproductive Health Survey, Jamaica 2008 many as four visits were placed to each household with eligible respondents who were not at home during the initial household approach. Almost all respondents who were selected to participate and who could be reached agreed to be interviewed. Less than one percent of eligible women and 2.5% of eligible men refused to be interviewed, and 2.5% of women and 3.2% of men could not be located. Response rates were not significantly different by residence, except for Kingston Metropolitan Area, where the participation rate among young men was slightly lower (89.8%). Kingston Metropolitan Area Other Urban Rural 1 2 3 4 Household visits Identified eligible respondent 20.0 17.1 19.8 20.9 17.0 19.6 22.0 22.9 No eligible respondent 58.0 47.8 57.2 61.5 53.7 63.1 60.2 57.8 Occupant not at home 3.0 1.3 4.9 2.6 2.9 2.4 1.4 5.7 Household refusal 1.7 3.9 1.8 1.1 3.2 0.2 1.0 1.6 Unoccupied household 6.2 6.2 6.5 6.1 6.1 6.4 6.1 6.6 Other 11.0 23.7 9.8 7.8 17.1 8.3 9.4 5.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of households visited 14,729 2,479 4,052 8,198 5,118 2,933 3,679 2,999 Eligible men (15–24) Completed interviews 94.4 89.8 94.6 95.3 90.7 96.2 95.7 95.9 Eligible absent 3.2 2.6 2.7 3.5 4.0 3.0 2.1 3.5 Eligible refusal 2.5 7.6 2.6 1.2 5.3 0.9 2.2 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of eligible men identified 2,941 423 802 1,716 870 574 810 687 No. of completed interviews 2,775 380 759 1,636 789 552 775 659 Table 1.6B Results of Household Visits and Individual Interview Status of Eligible Men Aged 15–24 Years by Residence and Health Region (Percent Distribution) Household Visits and Eligibility Total Residence Health Region Even though the overall response rate was similar in urban and rural areas, eligible respondents in urban areas were somewhat more likely to refuse to be interviewed. Chapter 1: Background 15 1.7 Sampling Weights Because the sample design is not self-weighting, it was necessary to weight observations for data analysis. The initial two of three weights represented the differential selection of households in each sampling region and the selection of one eligible respondent per household, which compensates for the fact that some households included more than one eligible female or male respondent. The number of households in each sampling region was compared with the number of households per sampling region estimated in the 2001 census projections. The ratio between the estimate of all existent households and sample-selected households in each sampling region represents the sampling-region-specific household expansion factor. This factor was later normalized so that the sum of the household weights was equal to the total number of households in the sample. The variation in this weight reflects variation in the selection probability of the households within each sampling region and parish. Tabulations using these two weights (sampling-region-specific household weight and one- respondent selection weight) were used to compare demographic characteristics of respondents with completed interviews with the 2008 population projections for Jamaica by age group, sex, and place of residence. The age distribution of the 2008 RHS sample closely corresponded to the female population projections, except for overrepresenting women aged 45–49 years and underrepresenting women aged 30–39 years, regardless of the place of residence. The age distribution of the male sample was similar to the distribution in the census projections. Thus, a post-survey adjustment for the age distribution of the female sample was multiplied by the two weights mentioned above. The post-survey adjustment was based on the 2008 projections of the population by sex, age, and residence. For each sub-class, the post- survey adjustment factor was the ratio of the known national value to the sample estimate of that value. As a result, the final survey weight is the product of 3 weights for the female sample (a household weight, a one-respondent-per-household weight, and a post-stratification weight) and 2 weights for the male sample (a household weight, a one-respondent-per-household weight). Beginning with Chapter 2, all survey results are based on analyses weighted by the final weight. Wt Female sample final = Wt sampling region * Wt one eligible respondent * Wt post-stratification Wt Male sample final = Wt sampling region * Wt one eligible respondent 16 Reproductive Health Survey, Jamaica 2008 Chapter 2: Characteristics of the sample 17 Chapter 2 Characteristics of the sample The 2008 RHS survey documents a wide array of key reproductive health outcomes and their determinants for women of reproductive age (women aged 15–49 years) and young adult men (aged 15–24 years). To better understand these outcomes, Chapter 2 presents the main characteristics of the survey respondents, using key variables that will be repeated throughout the report. Geographic key variables are area of residence, including Kingston Metropolitan Area, other urban area, and rural area; four health regions; and 14 parishes. Key demographic variables are the age at the time of the interview, which is grouped by five years (or by ten years in some tables in other chapters), and current relationship status. The latter consists of six types: three formal union relationships—legal marriage, common-law union, and visiting union—two more informal partnerships—include boyfriend/girlfriend with sexual relationship and boyfriend/girlfriend without sexual relationship—and respondents without a regular partner at the time of the interview. The distinction among various types of partnerships by whether they include sexual relations or not is important particularly for its relevance to fertility and contraceptive use. Note: women and men who did not have steady partners at the time of the survey include those who have previously been in a marital/consensual/visiting union or had a boyfriend/girlfriend. Socioeconomic variables include education level in years categorized into 0–9, 10–12, and 13 or more years of schooling and the wealth status of the households interviewed. The wealth status is based on household assets, including durable goods (refrigerator, television, car, computer, etc.) and dwelling characteristics (type of source for drinking water, toilet facilities, fuel used for cooking, and the household crowdedness). To construct the index, each household asset was assigned a weight or a factor score generated through principal component analysis. The resulting asset scores were standardized to have a standard normal distribution with a mean of zero and a standard deviation of one. Each household was assigned a standardized score reflecting its existing set of assets and possessions, and overall scores were generated by summing up the standardized asset-specific scores. Next, the sample of households was divided into quintiles: the households with the lowest 20% of the total asset scores became the lowest wealth quintile, the next 20% became the second wealth quintile, etc. Each respondent was ranked according to the wealth quintile of the household in which she or he resided. Thus, the wealth index measures the standard of living of a household relative to other households, indicating that respondents living in households with the second wealth quintile, 18 Reproductive Health Survey, Jamaica 2008 for example, have better socioeconomic status (SES) than those in the lowest wealth quintile and worse SES than respondents living in the middle wealth quintile. The wealth index is not an indication of whether respondents are living in poverty or not. It is also worth mentioning that previous RHS surveys in Jamaica did not use the wealth index to characterize the SES of the households. Previous surveys used a socioeconomic index based on equal values assigned for possession of household amenities and goods. The resulting scores ranged from 0–9 or 0–10, where 0 represented the lower end (i.e. no score-related amenities or goods in the household) and 9 or 10 represented the higher end (all items present in the household). The score was further divided into terciles to create three levels of the SES of the household. To facilitate comparisons of reproductive health indicators by the SES of the respondents interviewed in the 2008 survey with the results collected in previous surveys, the wealth index created in 2008 is also used to create a distribution of households by terciles. The wealth terciles are based on the principal component analysis and classify the households in the sample as being in the lowest 33% of the total asset score, the middle 33%, and the highest 33%. Thus, the trend comparison of indicators by socioeconomic status should be interpreted with caution, since slightly different methodology for assessing the SES was employed in 2008. 2.1 Age The first demographic variable is age. The percent distribution by five-year age cohort is shown in Figure 2.1. In the male sample, 59.5% were aged 15–19 years, and 40.5% were aged 20–24 years. Figure 2.1 Percent Distribution of Women Aged 15-49 Years Reproductive Health Survey: Jamaica, 2008 Chapter 2: Characteristics of the sample 19 2.2 Partnership Status According to Table 2.2A and Figure 2.2, 14.8% of all female respondents were legally married, 22.5%, were in common-law unions, and 31.2%, were in visiting partnerships. One in four (24.9%) women of reproductive age did not have a regular partner at the time of the interview, 3.6% had a boyfriend that they had sexual relations with, and 3.1% had a boyfriend without sexual relations. Figure 2.2 Percent Distribution of Women Aged 15–49 Years by Partnership Status Reproductive Health Survey: Jamaica, 2008 Married 14.8% Visiting relationship 31.2% Common law union 22.5% Table 2.2A also shows the percent distribution of women in each partnership status according to key characteristics. Older women, particularly those aged 40 years or older, were more likely to be in a marital union than younger women (30.5%–32.6%). Women aged 20–24 and 25–29 years were most likely to be in a visiting partner relationship (49.3% and 41.7%, respectively). Boyfriend-girlfriend relationship was most common among women aged 15–19 years, among whom 10.6% reported a relationship that involved sexual activity and 11.5% reported no sexual intercourse with their partners. Marriage was the most common form of partnership among women with at least 13 years of schooling (29.6%) and among those living in households categorized to be in the highest wealth quintile (23.9%). Common law unions were more common among women with lower education attainment and those living in households with lower SES. Since only 8 men aged 15–24 years included in the RHS sample were legally married, young adult men in legal and consensual marriages were analyzed together in all tables related to male reproductive health indicators. Table 2.2B shows that 5.3% of young adult men were currently married or in consensual unions, 20.7% were in visiting relationships, 29.9% had girlfriends with 20 Reproductive Health Survey, Jamaica 2008 whom they had sexual relations, 15.6% had girlfriends without sexual relations, and 28.4% did not have steady partners. 2.3 Education Level Figure 2.3 and Table 2.3A show the percent distribution of women aged 14–49 years by the number of years of schooling. The majority of the women (63.7%) reported 10–12 years of schooling, followed by 22.7% of women with 0–9 years, and 13.6% with at least 13 years. As for young males, 24.1% had 0–9 years of schooling, 70.6% had 10–12 years, and 5.2% had at least 13 years in school (Table 2.3B). Interestingly, men aged 20–24 years were less likely to report postsecondary education (13 or more years of schooling) than their female counterparts (10.2% vs. 17.9%). 0-9 years 26.4% Figure 2.3 Percent Distribution of Women Aged 15–49 Years by Education Level (in Years) Reproductive Health Survey: Jamaica, 2008 Table 2.3A also shows the percent distribution of women in each education level by key background characteristics. In general, women residing in urban areas were better educated than those living in rural areas. For example, women in rural areas were more likely to report 0– 9 years of schooling (28.8%) and less likely to report 13 or more years of schooling (9.9%) than women residing in urban areas (20.3% and 18.7%, respectively), including the Kingston Metropolitan Area (14.4% and 12.4%, respectively). The regions with the least educated populations were health region 4 (33.0% of women with 0–9 years of education) and Clarendon parish (35.2% of women with 0–9 years of education). Similar patterns of education by background characteristics were observed among young adult men (Table 2.3B). Chapter 2: Characteristics of the sample 21 2.4 Wealth Quintile Similar to the pattern found for educational level, Table 2.4A also shows that the health region 4 appeared to be the poorest with about a third (34.0%) of the female respondents residing in households classified as being in the lowest wealth quintile. Women residing in St Elizabeth and Clarendon had the highest likelihood to reside in households with the lowest wealth quintile (40.0% and 37.7%, respectively). Legally married women were more likely to reside in households with the highest wealth quintile than women in other union status; almost one in three married women had the highest wealth quintile compared to only 12.0% of women in common-law unions and 18.2% of women in visiting relationships. Table 2.4B among men, rural residence, residence in health region 4 and 2, residence in St. Thomas, St. Mary, St. Elizabeth, and Clarendon parishes, low educational attainment, and having no steady relationship were associated with lower wealth quintiles. 2.5 Employment Status Figure 2.5 and Table 2.5A show the percent distribution of women aged 15–49 years by their employment status. Appxoximately half (43.5%) were employed, and 13.4% had participated in the labour force but were unemployed at the time of the survey. One in five (21.9%) women reported not working because they were “keeping house”, 15.0% were in school, and 5.8% were at home but not keeping house. Among young males, 38.3% were students, 35.5% were currently employed, and 19.7% were unemployed (Table 2.4B). Table 2.5A also shows that women in urban areas, particularly in Kingston Metropolitan Area, were more likely to be employed (50.9% for Kingston and 48.5% for other urban areas) than women in rural areas (35.8%). Rural residents had the highest unemployment rate (16.2%). As for parishes, unemployment rates were particularly high in St. Mary (29.8%) and St. Thomas (25.2%). The vast majority of women aged 15–19 years (64.3%) were students. Married women were more likely to be employed (61.0%) and less likely to be unemployed (6.9%) than women in other union status. Women with the highest level of education and those residing in households with the highest SES were more likely to be employed (66.3% and 57.9%, respectively) than women residing in households with lower wealth quintiles. 22 Reproductive Health Survey, Jamaica 2008 Figure 2.5 Percent Distribution of Women Aged 15–49 Years by Employment Status Reproductive Health Survey: Jamaica, 2008 Employed 43.5% Keeping house 21.9% Unemployed 13.4% When compared to young women aged 15–19 and 20–24 years, young adult men were twice as likely to be employed (15.5% and 65.2% for males vs. 7.1% and 34.3% for females) and much less likely to be unemployed (16.6% and 24.4% for males vs. 11.1% and 21.5% for females) (Tables 2.5A and B). Consistent with the gender differential in the current level of educational attainment, young women aged 20–24 years were more likely to report not working because they were in school, presumably in postgraduate school, when compared to their male counterparts (11.5% vs. 6.4%). 2.6 Church Attendance Figure 2.6 and Table 2.6A show the percent distribution of women aged 15–49 years by frequency of attendance in religious activities. One third (34.8%) reported attending religious services at least once a week and 22.1% attended church only on special occasions, such as weddings, funerals, and christenings. One in every 10 women (11.1%) said that they never attended any religious services. Adolescent women (41.3%) and women aged 40 years or older (38.2% and 51.7%, respectively) reported the highest levels of weekly attendance of religious services. Married women were more likely to attend religious services at least weekly (65.0%) than women in other union status, particularly those with common-law partners (15.3%). Finally, women with higher levels of education and those living in households with higher wealth quintiles were more likely to attend services frequently than women with lower education and SES. Chapter 2: Characteristics of the sample 23 Compared to young adult women, men aged 15–19 and 20–24 were less likely to attend church weekly and more likely to report never attending religious services (Tables 2.6A and 2.6B). Figure 2.6 Percent Distribution of Women Aged 15–49 Years by Frequency of Church Attendance Reproductive Health Survey: Jamaica, 2008 At least once a week 34.8% At least once a month 18.3% 2.7 Number of Children Born Alive Figure 2.7 and Table 2.7A show the percent distribution of women aged 15–49 years by the number of children they have that were born alive. One third (33.0%) of these women had no children born alive at the time of the survey. These rates were higher among residents of Kingston Metropolitan area, health region 1 and St Andrew parish (which is part of the health region 1) and lower among rural residents and residents of region 4 and St Elizabeth parish. Slightly more than one in five (21.6%) of women reported having one live birth, 17.7% reported 2 live births, and 27.7% reported 3 or more children born alive. Higher numbers of live births was associated with rural residence (32.7% of women reported at least 3 live births) and residence in health region 4. As expected, the number of live births was directly correlated with age, with the youngest women being the most likely to be childless and the women aged 45–49 years reporting the highest number of children born alive. Higher numbers of living children were also reported by women in legal and consensual unions, those with low educational attainment and those residing in households with lower wealth quintiles. Excepting men who were in legal or consensual unions, the vast majority of young men reported they had not yet fathered a child who was born alive (Table 2.7B). 24 Reproductive Health Survey, Jamaica 2008 Figure 2.7 Percent Distribution of Women Aged 15–49 Years by Number of Children Born Alive Reproductive Health Survey: Jamaica, 2008 None 33.08% 1 21.6% Chapter 2: Characteristics of the sample 25 Married Common Law Union Visiting Relationship Boyfriend with Sex Boyfriend without Sex No Steady Relationship Total 14.8 22.5 31.2 3.6 3.1 24.9 100.0 8,259 Residence Kingston Metropolitan Area 12.2 21.4 35.5 4.2 2.9 23.9 100.0 1,198 Other urban 16.1 22.8 30.5 2.5 3.0 25.1 100.0 2,283 Rural 14.9 22.8 29.8 4.2 3.2 25.1 100.0 4,778 Health region 1 13.6 21.9 32.8 3.6 3.2 24.9 100.0 2,340 2 14.4 24.7 26.4 4.2 3.4 26.9 100.0 1,761 3 14.5 26.0 28.0 4.1 2.5 24.9 100.0 2,313 4 17.7 19.2 33.7 2.6 3.2 23.5 100.0 1,845 Parish Kingston 10.0 20.5 40.0 4.0 1.9 23.6 100.0 644 St. Andrew 12.9 21.3 33.5 4.2 3.5 24.7 100.0 636 St. Thomas 12.0 26.0 33.6 5.9 2.0 20.6 100.0 504 Portland 17.8 25.1 19.7 5.5 2.9 28.9 100.0 516 St. Mary 10.5 27.8 23.2 4.9 1.6 32.0 100.0 542 St. Ann 15.9 22.1 31.7 3.1 5.0 22.2 100.0 703 Trelawny 13.5 25.3 28.3 6.3 2.2 24.4 100.0 516 St. James 16.3 25.5 29.5 4.0 2.8 21.9 100.0 635 Hanover 13.2 18.6 29.3 2.1 2.9 33.9 100.0 541 Westmoreland 13.6 30.4 25.4 3.9 2.2 24.5 100.0 621 St. Elizabeth 15.3 19.6 37.0 3.1 2.0 23.0 100.0 528 Manchester 20.2 16.5 32.4 0.9 5.4 24.6 100.0 668 Clarendon 17.3 21.4 32.5 3.9 1.9 23.0 100.0 649 St. Catherine 15.3 22.2 30.7 2.7 3.2 25.9 100.0 556 Age group 15–19 0.0 6.5 19.3 10.6 11.6 52.0 100.0 1,229 20–24 3.6 24.6 49.3 5.5 3.0 14.0 100.0 1,114 25–29 10.6 29.1 41.7 2.3 1.0 15.3 100.0 1,350 30–34 19.6 30.5 32.6 0.7 1.1 15.5 100.0 1,219 35–39 22.6 27.4 28.3 1.3 0.5 19.9 100.0 1,221 40–44 30.5 22.5 19.9 0.6 0.2 26.3 100.0 1,084 45–49 32.6 18.6 20.7 0.3 0.4 27.4 100.0 1,042 Education level (in years)* 0–9 15.4 27.6 23.6 2.8 2.5 28.1 100.0 2,183 10–12 12.3 23.2 34.0 3.8 3.3 23.4 100.0 5,078 13 or more 25.3 10.9 30.6 3.8 3.0 26.4 100.0 995 Wealth quintile Lowest 10.5 28.4 32.4 2.5 2.1 24.1 100.0 2,001 Second 10.5 28.7 32.7 4.0 2.6 21.4 100.0 1,716 Middle 13.6 24.3 31.0 4.2 3.1 23.8 100.0 1,668 Fourth 15.2 18.0 31.5 3.5 4.3 27.5 100.0 1,650 Highest 23.9 13.5 28.5 3.7 3.2 27.2 100.0 1,224 *Excludes 3 women with missing information. Current Partnership Status among Women Aged 15–49 Years Table 2.2A Characteristic Total No. of Cases Current Relationship Status Reproductive Health Survey: Jamaica, 2008 by Selected Characteristics 26 Reproductive Health Survey, Jamaica 2008 Married/ Common Law Union Visiting Relationship Girlfriend with Sex Girlfriend without Sex No Steady Relationship Total 5.3 20.7 29.9 15.6 28.4 100.0 2,775 Residence Kingston Metropolitan Area 4.1 25.9 41.9 12.7 15.4 100.0 380 Other urban 7.0 19.7 26.5 17.4 29.4 100.0 759 Rural 4.7 19.8 28.4 15.4 31.7 100.0 1,636 Health region 1 4.8 28.0 32.3 16.2 18.8 100.0 789 2 6.4 17.2 34.1 13.9 28.5 100.0 552 3 7.8 13.8 27.5 11.8 39.1 100.0 775 4 3.1 19.2 26.9 19.7 31.2 100.0 659 Parish Kingston 7.0 30.0 39.4 13.7 9.9 100.0 209 St. Andrew 2.7 30.2 37.3 11.6 18.2 100.0 201 St. Thomas 6.8 23.9 23.6 16.7 29.0 100.0 212 Portland 7.2 13.1 34.6 11.9 33.2 100.0 182 St. Mary 8.7 23.1 30.4 12.6 25.2 100.0 186 St. Ann 4.1 14.5 36.8 16.0 28.6 100.0 184 Trelawny 3.2 8.9 48.4 8.8 30.6 100.0 170 St. James 9.4 16.9 23.1 18.8 31.8 100.0 215 Hanover 8.9 12.8 23.9 12.5 41.8 100.0 181 Westmoreland 6.9 12.7 26.5 4.3 49.6 100.0 209 St. Elizabeth 2.1 37.4 17.1 14.9 28.5 100.0 217 Manchester 2.6 14.5 25.7 18.1 39.1 100.0 236 Clarendon 4.6 8.5 36.7 25.5 24.7 100.0 206 St. Catherine 6.0 26.1 27.0 21.5 19.4 100.0 167 Age group 15–19 0.4 9.7 30.9 22.8 36.1 100.0 1,652 20–24 12.4 36.7 28.5 5.2 17.2 100.0 1,123 Education level (in years)* 0–9 3.1 9.3 20.7 22.0 44.9 100.0 687 10–12 6.1 23.9 32.7 14.2 23.1 100.0 1,944 13 or more 5.1 30.5 37.0 6.9 20.4 100.0 130 Wealth quintile Lowest 5.1 13.6 28.5 12.4 40.5 100.0 632 Second 4.2 20.6 29.4 17.0 28.9 100.0 620 Middle 7.7 21.6 30.9 16.0 23.8 100.0 512 Fourth 4.6 25.8 28.9 15.8 24.9 100.0 538 Highest 5.0 22.4 32.3 17.0 23.4 100.0 473 *Excludes 14 men with missing information. Reproductive Health Survey: Jamaica, 2008 by Selected Characteristics Current Partnership Status of Men Aged 15–24 Years Table 2.2B Characteristic Total No. of Cases Current Relationship Status Chapter 2: Characteristics of the sample 27 0–9 10–12 13 or More Total 22.7 63.7 13.6 100.0 8,256 Residence Kingston Metropolitan Area 14.4 73.3 12.4 100.0 1,198 Other urban 20.3 61.1 18.7 100.0 2,281 Rural 28.8 61.4 9.9 100.0 4,777 Health region 1 18.1 65.3 16.6 100.0 2,339 2 22.8 65.2 12.0 100.0 1,760 3 22.6 68.1 9.3 100.0 2,313 4 33.0 55.0 12.0 100.0 1,844 Parish Kingston 21.1 68.2 10.7 100.0 644 St. Andrew 13.6 73.6 12.8 100.0 636 St. Thomas 24.6 66.9 8.5 100.0 503 Portland 31.5 54.2 14.4 100.0 516 St. Mary 23.0 66.8 10.2 100.0 541 St. Ann 19.0 68.6 12.4 100.0 703 Trelawny 27.0 60.4 12.6 100.0 516 St. James 21.0 69.6 9.4 100.0 635 Hanover 23.9 70.1 6.1 100.0 541 Westmoreland 21.5 69.5 9.0 100.0 621 St. Elizabeth 34.3 56.4 9.3 100.0 527 Manchester 29.5 55.1 15.4 100.0 668 Clarendon 35.2 54.1 10.7 100.0 649 St. Catherine 20.9 56.6 22.5 100.0 556 Age group 15–19 24.4 71.4 4.2 100.0 1,229 20–24 9.0 73.2 17.9 100.0 1,114 25–29 15.0 66.3 18.7 100.0 1,350 30–34 21.1 61.7 17.2 100.0 1,219 35–39 25.8 60.2 14.0 100.0 1,220 40–44 34.0 53.4 12.6 100.0 1,083 45–49 42.2 47.5 10.3 100.0 1,041 Current relationship status Married 23.8 53.0 23.3 100.0 1,440 Common law union 27.9 65.6 6.6 100.0 2,157 Visiting relationship 17.2 69.5 13.3 100.0 2,278 Boyfriend with sex 18.0 67.7 14.3 100.0 281 Boyfriend without sex 18.2 68.5 13.3 100.0 197 No steady relationship 25.6 59.9 14.4 100.0 1,903 Wealth quintile Lowest 43.1 54.3 2.5 100.0 2,000 Second 27.8 67.6 4.6 100.0 1,714 Middle 19.9 71.5 8.6 100.0 1,668 Fourth 14.9 68.2 16.9 100.0 1,650 Highest 7.7 57.3 35.0 100.0 1,224 *Excludes 3 women with missing information. by Selected Characteristics Education Level among Women Aged 15–49 Years Table 2.3A Characteristic Total Reproductive Health Survey: Jamaica, 2008 Education Level (in Years)* No. of Cases 28 Reproductive Health Survey, Jamaica 2008 0–9 10–12 13 or More Total 24.1 70.6 5.2 100.0 2,761 Residence Kingston Metropolitan Area 16.4 75.6 8.0 100.0 377 Other urban 22.2 71.3 6.5 100.0 756 Rural 27.6 68.7 3.6 100.0 1,628 Health region 1 19.0 74.3 6.7 100.0 783 2 21.1 74.6 4.3 100.0 551 3 28.0 68.9 3.1 100.0 773 4 29.3 65.0 5.7 100.0 654 Parish Kingston 17.2 79.2 3.6 100.0 207 St. Andrew 15.8 75.9 8.2 100.0 198 St. Thomas 28.5 70.2 1.3 100.0 212 Portland 30.0 64.1 5.9 100.0 182 St. Mary 15.7 79.3 5.0 100.0 186 St. Ann 20.8 76.3 2.9 100.0 183 Trelawny 19.0 72.6 8.4 100.0 170 St. James 26.2 70.9 2.8 100.0 214 Hanover 26.7 70.0 3.3 100.0 181 Westmoreland 34.0 64.6 1.4 100.0 208 St. Elizabeth 29.7 67.3 3.1 100.0 217 Manchester 27.5 64.5 8.0 100.0 235 Clarendon 31.0 63.6 5.4 100.0 202 St. Catherine 20.8 72.2 7.0 100.0 166 Age group 15–19 30.5 67.7 1.8 100.0 1,645 20–24 14.9 74.8 10.2 100.0 1,116 Current relationship status Married/common law union 14.0 81.0 5.0 100.0 161 Visiting relationship 10.9 81.4 7.7 100.0 550 Girlfriend with sex 16.6 76.9 6.4 100.0 827 Girlfriend without sex 33.9 63.8 2.3 100.0 410 No steady relationship 38.4 57.9 3.8 100.0 813 Wealth quintile Lowest 39.8 57.9 2.3 100.0 628 Second 27.4 69.7 2.9 100.0 619 Middle 22.3 75.4 2.4 100.0 507 Fourth 14.6 77.3 8.2 100.0 535 Highest 16.0 73.2 10.8 100.0 472 *Excludes 14 men with missing information. by Selected Characteristics Education Level of Men Aged 15–24 Years Table 2.3B Characteristic Total Reproductive Health Survey: Jamaica, 2008 Education Level (in Years)* No. of Cases Chapter 2: Characteristics of the sample 29 Lowest Second Middle Fourth Highest Total 20.9 18.5 20.0 20.7 19.9 100.0 8,259 Residence Kingston Metropolitan Area 3.4 15.3 23.2 26.0 32.2 100.0 1,198 Other urban 15.1 14.9 19.1 24.2 26.7 100.0 2,283 Rural 34.0 23.0 19.2 15.4 8.5 100.0 4,778 Health region 1 11.6 16.4 19.2 23.7 29.1 100.0 2,340 2 28.7 20.8 23.8 16.7 10.0 100.0 1,761 3 22.3 20.7 21.0 22.3 13.8 100.0 2,313 4 34.9 19.4 18.4 15.2 12.0 100.0 1,845 Parish Kingston 6.1 25.2 28.6 20.7 19.5 100.0 644 St. Andrew 3.3 14.7 23.3 26.8 31.9 100.0 636 St. Thomas 30.3 29.1 23.3 11.9 5.4 100.0 504 Portland 20.3 20.3 21.7 19.6 18.2 100.0 516 St. Mary 33.5 21.5 22.5 14.7 7.7 100.0 542 St. Ann 28.5 20.5 25.6 17.0 8.4 100.0 703 Trelawny 31.2 20.1 15.6 27.2 6.0 100.0 516 St. James 15.6 21.4 26.0 18.0 19.0 100.0 635 Hanover 21.5 17.2 19.3 29.9 12.2 100.0 541 Westmoreland 25.9 21.8 18.6 21.2 12.4 100.0 621 St. Elizabeth 40.0 20.8 18.1 14.1 7.0 100.0 528 Manchester 27.8 19.3 18.7 18.4 15.8 100.0 668 Clarendon 37.7 18.5 18.3 13.2 12.2 100.0 649 St. Catherine 17.9 14.7 13.0 22.9 31.4 100.0 556 Age group 15–19 17.9 17.2 20.7 23.3 21.0 100.0 1,229 20–24 20.2 20.6 20.3 17.8 21.0 100.0 1,114 25–29 21.0 17.9 20.9 22.1 18.1 100.0 1,350 30–34 22.2 19.0 21.3 20.5 17.1 100.0 1,219 35–39 23.0 19.4 17.8 19.1 20.8 100.0 1,221 40–44 21.2 18.5 19.2 19.5 21.6 100.0 1,084 45–49 21.8 16.0 18.5 23.2 20.5 100.0 1,042 Current relationship status Married 14.9 13.1 18.5 21.3 32.3 100.0 1,441 Common law union 26.3 23.6 21.5 16.6 12.0 100.0 2,158 Visiting relationship 21.6 19.4 19.8 21.0 18.2 100.0 2,279 Boyfriend with sex 14.8 20.8 23.5 20.2 20.7 100.0 281 Boyfriend without sex 14.0 15.9 20.2 29.0 20.9 100.0 197 No steady relationship 20.2 15.9 19.1 22.9 21.8 100.0 1,903 Education level (in years)* 0–9 39.6 22.6 17.5 13.6 6.8 100.0 2,183 10–12 17.8 19.6 22.4 22.2 18.0 100.0 5,078 13 or more 3.9 6.2 12.7 25.8 51.4 100.0 995 *Excludes 3 women with missing information. Reproductive Health Survey: Jamaica, 2008 by Selected Characteristics Percentage Distribution of Women Aged 15–49 Years by the Wealth Quintile of Their Households Table 2.4A Characteristic Wealth Quintile Total No. of Cases 30 Reproductive Health Survey, Jamaica 2008 Lowest Second Middle Fourth Highest Total 20.4 20.1 20.6 20.2 18.7 100.0 2,775 Residence Kingston Metropolitan Area 5.5 12.7 26.3 31.2 24.3 100.0 380 Other urban 12.0 16.5 21.8 22.6 27.1 100.0 759 Rural 29.9 24.5 18.2 15.5 11.9 100.0 1,636 Health region 1 10.0 18.1 25.2 22.6 24.1 100.0 789 2 29.3 18.2 18.4 19.3 14.8 100.0 552 3 19.2 24.9 17.8 22.4 15.7 100.0 775 4 31.9 19.1 18.0 15.1 15.9 100.0 659 Parish Kingston 8.7 25.7 25.8 27.1 12.6 100.0 209 St. Andrew 5.3 12.5 25.3 30.9 26.0 100.0 201 St. Thomas 29.8 36.9 11.8 14.3 7.2 100.0 212 Portland 26.8 15.7 19.7 20.9 17.0 100.0 182 St. Mary 31.4 26.3 16.5 17.4 8.5 100.0 186 St. Ann 29.0 13.0 19.3 19.9 18.8 100.0 184 Trelawny 24.9 25.3 20.1 17.5 12.2 100.0 170 St. James 12.7 16.8 21.2 29.4 19.8 100.0 215 Hanover 19.5 29.5 17.0 19.2 14.8 100.0 181 Westmoreland 24.4 31.8 13.4 17.8 12.7 100.0 209 St. Elizabeth 38.8 14.3 20.4 14.9 11.6 100.0 217 Manchester 28.0 17.0 14.8 17.0 23.3 100.0 236 Clarendon 30.2 25.5 19.5 13.2 11.7 100.0 206 St. Catherine 11.3 18.6 27.7 14.5 27.9 100.0 167 Age group 15–19 20.7 21.7 21.2 17.6 18.8 100.0 1,652 20–24 20.0 17.8 19.7 24.1 18.4 100.0 1,123 Current relationship status Married/common law union 19.4 15.8 29.9 17.5 17.4 100.0 162 Visiting relationship 13.4 19.9 21.4 25.1 20.1 100.0 554 Girlfriend with sex 19.4 19.7 21.3 19.5 20.1 100.0 829 Girlfriend without sex 16.2 21.9 21.1 20.5 20.3 100.0 410 No steady relationship 29.1 20.5 17.3 17.8 15.4 100.0 820 Education level (in years)* 0–9 33.6 22.9 18.9 12.2 12.4 100.0 687 10–12 16.7 19.9 21.8 22.1 19.4 100.0 1,944 13 or more 8.9 11.1 9.3 31.7 38.9 100.0 130 *Excludes 14 men with missing information. Reproductive Health Survey: Jamaica, 2008 by Selected Characteristics Percentage Distribution of Men Aged 15–24 Years by the Wealth Quintile of Their Households Table 2.4B Characteristic Wealth Quintile Total No. of Cases Chapter 2: Characteristics of the sample 31 Employed Unemployed Keeping house Student At Home, not keeping house Incapable of working Total 43.5 13.4 21.9 15.0 5.8 0.5 100.0 8,259 Residence Kingston Metropolitan Area 50.9 8.2 18.7 17.8 4.4 0.1 100.0 1,198 Other urban 48.5 13.0 19.6 13.8 4.6 0.5 100.0 2,283 Rural 35.8 16.2 25.2 14.6 7.6 0.7 100.0 4,778 Health region 1 49.6 10.9 16.7 16.2 6.5 0.2 100.0 2,340 2 36.0 24.4 19.3 15.0 3.6 1.7 100.0 1,761 3 42.4 9.8 26.4 14.2 6.8 0.5 100.0 2,313 4 35.6 15.8 30.3 12.9 4.9 0.4 100.0 1,845 Parish Kingston 50.7 7.4 22.4 14.0 5.1 0.4 100.0 644 St. Andrew 49.5 8.9 15.7 18.9 7.0 0.0 100.0 636 St. Thomas 38.1 25.2 18.4 12.1 3.6 2.6 100.0 504 Portland 32.9 22.1 28.9 12.2 3.8 0.1 100.0 516 St. Mary 37.1 29.8 15.9 13.8 2.6 0.8 100.0 542 St. Ann 36.5 21.2 17.9 17.0 4.4 3.1 100.0 703 Trelawny 35.6 6.8 35.5 12.2 8.2 1.7 100.0 516 St. James 47.9 10.2 27.9 11.8 1.9 0.2 100.0 635 Hanover 39.2 9.2 8.0 19.9 23.3 0.3 100.0 541 Westmoreland 40.9 11.1 28.6 15.1 4.0 0.3 100.0 621 St. Elizabeth 33.1 8.0 38.4 12.0 8.5 0.0 100.0 528 Manchester 38.4 18.3 25.3 15.0 2.8 0.2 100.0 668 Clarendon 35.0 19.2 28.9 11.7 4.3 0.9 100.0 649 St. Catherine 51.1 11.3 16.3 14.7 6.5 0.0 100.0 556 Age group 15–19 7.1 11.1 8.4 64.3 8.8 0.3 100.0 1,229 20–24 34.3 21.5 22.6 11.5 9.4 0.6 100.0 1,114 25–29 53.3 14.8 23.0 4.2 4.3 0.4 100.0 1,350 30–34 55.2 13.2 25.7 2.4 2.7 0.7 100.0 1,219 35–39 57.2 11.4 24.0 0.9 6.2 0.2 100.0 1,221 40–44 56.8 11.3 27.7 0.2 3.3 0.6 100.0 1,084 45–49 59.2 7.0 28.8 0.6 3.8 0.6 100.0 1,042 Current relationship status Married 61.0 6.9 25.8 2.2 3.8 0.3 100.0 1,441 Common law union 46.6 15.2 31.5 1.8 4.6 0.4 100.0 2,158 Visiting relationship 46.4 16.9 22.9 6.7 6.7 0.4 100.0 2,279 Boyfriend with sex 28.8 13.7 8.6 43.7 5.2 0.0 100.0 281 Boyfriend without sex 11.6 11.1 6.4 67.0 4.1 0.0 100.0 197 No steady relationship 32.5 11.5 13.4 34.2 7.4 0.9 100.0 1,903 Education level (in years)* 0–9 36.0 11.0 28.9 16.6 6.5 1.1 100.0 2,183 10–12 41.3 15.3 22.8 14.3 6.1 0.3 100.0 5,078 13 or more 66.3 8.7 5.6 15.5 3.7 0.2 100.0 995 Wealth quintile Lowest 26.7 19.6 35.4 10.0 7.4 1.0 100.0 2,001 Second 39.9 16.2 26.0 10.3 7.1 0.4 100.0 1,716 Middle 44.4 14.2 20.9 15.1 4.8 0.5 100.0 1,668 Fourth 48.7 10.5 16.9 18.7 4.8 0.5 100.0 1,650 Highest 57.9 6.6 10.0 20.4 5.1 0.0 100.0 1,224 *Excludes 3 women with missing information. Table 2.5A Employment Status among Women Aged 15–49 Years by Selected Characteristics Reproductive Health Survey: Jamaica, 2008 Characteristic Employment Status Total No. of Cases 32 Reproductive Health Survey, Jamaica 2008 Employed Unemployed Keeping House Student At Home, Not Keeping House Incapable of Working Total 35.8 19.7 0.7 38.3 5.1 0.3 100.0 2,775 Residence Kingston Metropolitan Area 36.6 17.8 0.0 40.5 5.1 0.0 100.0 380 Other urban 36.0 18.5 0.7 41.3 3.6 0.0 100.0 759 Rural 35.4 21.1 1.0 35.8 6.0 0.6 100.0 1,636 Health region 1 35.9 17.9 0.2 40.4 5.6 0.0 100.0 789 2 31.4 22.1 2.5 37.1 6.5 0.3 100.0 552 3 43.3 19.8 0.5 33.0 2.9 0.5 100.0 775 4 30.3 21.1 0.9 41.1 5.9 0.7 100.0 659 Parish Kingston 38.0 16.7 0.2 34.3 10.9 0.0 100.0 209 St. Andrew 37.3 15.7 0.0 40.2 6.9 0.0 100.0 201 St. Thomas 32.1 15.8 0.8 41.0 10.3 0.0 100.0 212 Portland 24.0 28.4 1.9 34.4 11.1 0.3 100.0 182 St. Mary 35.9 22.0 1.4 34.2 5.7 0.8 100.0 186 St. Ann 31.7 18.9 3.7 40.9 4.8 0.0 100.0 184 Trelawny 39.6 18.2 0.9 37.3 1.6 2.4 100.0 170 St. James 42.8 19.6 0.5 33.6 3.5 0.0 100.0 215 Hanover 42.4 19.2 0.5 36.4 1.2 0.4 100.0 181 Westmoreland 45.9 20.9 0.3 29.0 3.7 0.4 100.0 209 St. Elizabeth 39.4 17.7 0.3 34.1 7.0 1.5 100.0 217 Manchester 28.0 17.3 0.2 51.4 3.1 0.0 100.0 236 Clarendon 24.8 28.2 2.2 36.0 8.2 0.6 100.0 206 St. Catherine 34.7 21.0 0.2 42.0 2.1 0.0 100.0 167 Age group 15–19 15.5 16.6 0.9 60.3 6.4 0.3 100.0 1,652 20–24 65.2 24.4 0.5 6.4 3.2 0.3 100.0 1,123 Current relationship status Married/common law union 81.0 15.9 0.4 0.6 2.1 0.0 100.0 162 Visiting relationship 64.2 19.1 0.4 11.7 4.5 0.1 100.0 554 Girlfriend with sex 34.5 25.3 1.1 33.7 5.4 0.0 100.0 829 Girlfriend without sex 16.6 10.9 0.9 67.9 3.6 0.1 100.0 410 No steady relationship 18.4 19.9 0.5 53.4 6.7 1.0 100.0 820 Education level (in years)* 0–9 22.7 13.1 0.5 56.8 5.9 1.0 100.0 687 10–12 40.5 22.0 0.8 31.7 5.0 0.1 100.0 1,944 13 or more 33.9 19.9 1.3 42.6 2.3 0.0 100.0 130 Wealth quintile Lowest 34.1 24.5 1.3 33.4 6.1 0.6 100.0 632 Second 35.0 18.7 1.3 37.8 6.8 0.4 100.0 620 Middle 33.4 22.4 0.1 40.0 3.8 0.3 100.0 512 Fourth 40.9 18.4 0.4 36.6 3.3 0.3 100.0 538 Highest 35.5 14.1 0.6 43.9 5.8 0.0 100.0 473 *Excludes 14 men with missing information. Table 2.5B Employment Status of Men Aged 15–24 Years by Selected Characteristics Reproductive Health Survey: Jamaica, 2008 Characteristic Employment Status Total No. of Cases Chapter 2: Characteristics of the sample 33 At Least Once a Week At Least Once a Month Less Than Once a Month On Special Occasions Never Total 34.8 18.3 13.7 22.1 11.1 100.0 8,241 Residence Kingston Metropolitan Area 30.9 15.2 8.1 26.6 19.2 100.0 1,198 Other urban 35.8 18.5 13.7 22.6 9.4 100.0 2,279 Rural 35.9 19.6 16.3 19.4 8.7 100.0 4,764 Health region 1 35.3 17.5 9.9 24.7 12.6 100.0 2,340 2 35.0 16.1 22.2 19.9 6.7 100.0 1,761 3 32.8 18.5 17.1 19.7 12.0 100.0 2,297 4 35.6 21.2 13.6 19.8 9.8 100.0 1,843 Parish Kingston 23.2 12.2 8.4 38.1 18.1 100.0 644 St. Andrew 34.2 16.9 8.5 22.4 18.0 100.0 636 St. Thomas 37.8 17.2 11.6 22.9 10.6 100.0 504 Portland 36.9 17.7 15.6 21.4 8.5 100.0 516 St. Mary 33.2 15.8 17.9 22.6 10.5 100.0 542 St. Ann 35.5 15.7 28.4 17.2 3.1 100.0 703 Trelawny 34.4 10.7 27.1 15.6 12.2 100.0 516 St. James 31.6 22.0 15.7 15.4 15.3 100.0 632 Hanover 34.7 11.2 14.3 34.0 5.8 100.0 537 Westmoreland 32.5 21.8 14.7 20.1 10.8 100.0 612 St. Elizabeth 35.2 18.2 18.4 17.0 11.1 100.0 528 Manchester 41.3 20.4 10.9 19.4 8.1 100.0 666 Clarendon 30.7 24.1 12.6 22.3 10.3 100.0 649 St. Catherine 38.3 19.2 11.1 24.8 6.7 100.0 556 Age group 15–19 41.4 18.3 13.8 14.1 12.4 100.0 1,224 20–24 29.7 16.7 15.0 23.1 15.4 100.0 1,112 25–29 24.1 22.8 14.4 28.9 9.8 100.0 1,349 30–34 32.1 16.3 13.8 27.5 10.4 100.0 1,214 35–39 34.3 18.8 13.1 23.0 10.9 100.0 1,220 40–44 38.2 19.6 13.7 19.8 8.7 100.0 1,082 45–49 51.8 14.1 10.3 16.5 7.3 100.0 1,040 Current relationship status Married 65.0 16.5 6.2 8.8 3.5 100.0 1,441 Common law union 15.4 20.6 17.2 31.3 15.5 100.0 2,153 Visiting relationship 20.3 18.1 16.4 29.9 15.2 100.0 2,273 Boyfriend with sex 23.3 24.3 20.3 21.6 10.6 100.0 281 Boyfriend without sex 52.1 13.6 14.7 11.8 7.8 100.0 196 No steady relationship 52.2 17.3 10.4 13.0 7.0 100.0 1,897 Education level (in years)* 0–9 31.9 17.1 14.5 21.7 14.8 100.0 2,178 10–12 33.1 17.8 14.0 23.7 11.3 100.0 5,068 13 or more 47.8 22.4 10.8 14.8 4.2 100.0 992 Wealth quintile Lowest 26.4 18.5 15.6 25.1 14.5 100.0 1,997 Second 28.9 16.3 17.0 24.5 13.2 100.0 1,711 Middle 32.9 19.0 13.8 23.3 11.0 100.0 1,666 Fourth 37.5 18.0 12.9 20.8 10.7 100.0 1,646 Highest 48.2 19.6 9.3 16.7 6.2 100.0 1,221 *Excludes 3 women with missing information. Table 2.6A Frequency of Church Attendance among Women Aged 15–49 Years by Selected Characteristics Reproductive Health Survey: Jamaica, 2008 Characteristic Frequency of Church Attendance Total No. of Cases 34 Reproductive Health Survey, Jamaica 2008 At Least Once a Week At Least Once a Month Less Than Once a Month On Special Occasions Never Total 19.8 13.0 15.6 30.6 20.9 100.0 2,760 Residence Kingston Metropolitan Area 12.2 10.6 14.3 46.5 16.4 100.0 376 Other urban 23.4 13.0 13.9 29.8 19.8 100.0 758 Rural 20.0 13.8 16.9 26.3 22.9 100.0 1,626 Health region 1 17.1 14.4 16.4 35.0 17.1 100.0 783 2 21.9 16.1 16.0 24.4 21.6 100.0 551 3 16.5 8.3 12.6 28.1 34.4 100.0 768 4 26.1 14.2 17.2 30.2 12.3 100.0 658 Parish Kingston 10.1 7.4 10.2 44.4 27.8 100.0 207 St. Andrew 15.7 12.5 14.3 42.5 14.9 100.0 199 St. Thomas 23.5 15.6 10.1 33.2 17.5 100.0 212 Portland 25.8 13.4 8.2 35.6 17.1 100.0 182 St. Mary 13.5 9.4 13.4 27.5 36.3 100.0 186 St. Ann 26.7 23.0 22.3 16.0 12.0 100.0 183 Trelawny 27.3 9.0 13.0 35.4 15.3 100.0 170 St. James 18.9 4.9 16.1 26.2 33.9 100.0 213 Hanover 16.4 11.3 12.9 21.8 37.6 100.0 177 Westmoreland 9.7 10.4 8.3 31.0 40.7 100.0 208 St. Elizabeth 17.5 11.7 22.4 32.6 15.7 100.0 217 Manchester 29.2 12.5 17.7 29.0 11.7 100.0 236 Clarendon 30.3 18.3 12.1 29.4 9.8 100.0 205 St. Catherine 18.8 17.8 21.3 25.2 16.9 100.0 165 Age group 15–19 25.3 16.2 17.1 23.8 17.6 100.0 1,645 20–24 11.8 8.4 13.4 40.6 25.7 100.0 1,115 Current relationship status Married/common law union 7.6 7.3 15.3 43.7 26.1 100.0 162 Visiting relationship 10.5 10.7 14.4 41.0 23.3 100.0 550 Girlfriend with sex 15.9 13.3 17.0 35.1 18.8 100.0 822 Girlfriend without sex 29.7 17.9 21.3 17.1 14.0 100.0 409 No steady relationship 27.7 13.0 11.9 23.4 24.2 100.0 817 Education level (in years)* 0–9 21.5 13.9 15.7 24.3 24.5 100.0 681 10–12 19.2 12.5 15.8 32.1 20.3 100.0 1,936 13 or more 20.1 16.2 10.7 40.8 12.2 100.0 129 Wealth quintile Lowest 19.0 8.7 11.8 30.3 30.2 100.0 627 Second 17.2 15.3 14.0 28.5 25.0 100.0 615 Middle 19.3 14.4 15.8 32.1 18.4 100.0 512 Fourth 18.0 11.9 18.0 35.1 17.0 100.0 537 Highest 26.3 15.1 18.6 26.8 13.2 100.0 469 *Excludes 14 men with missing information. Table 2.6B Frequency of Church Attendance among Men Aged 15–24 Years by Selected Characteristics Reproductive Health Survey: Jamaica, 2008 Characteristic Frequency of Church Attendance Total No. of Cases Chapter 2: Characteristics of the sample 35 0 1 2 3 4 or More Total 33.0 21.6 17.7 12.0 15.7 100.0 8,259 Residence Kingston Metropolitan Area 37.7 24.6 17.3 10.3 10.1 100.0 1,198 Other urban 33.3 22.3 18.5 12.5 13.5 100.0 2,283 Rural 30.6 19.6 17.1 12.5 20.2 100.0 4,778 Health region 1 36.6 23.1 17.7 11.4 11.2 100.0 2,340 2 31.1 19.3 17.0 12.9 19.8 100.0 1,761 3 31.0 21.5 17.8 11.5 18.2 100.0 2,313 4 28.5 20.0 17.8 13.3 20.4 100.0 1,845 Parish Kingston 31.2 18.2 20.8 13.8 16.1 100.0 644 St. Andrew 38.5 26.0 16.6 9.5 9.5 100.0 636 St. Thomas 26.5 18.8 24.1 12.7 17.9 100.0 504 Portland 26.6 19.7 17.7 14.4 21.7 100.0 516 St. Mary 28.9 21.8 16.6 11.3 21.5 100.0 542 St. Ann 34.7 17.1 17.1 13.4 17.6 100.0 703 Trelawny 26.1 21.8 14.9 12.4 24.8 100.0 516 St. James 27.8 23.2 19.2 11.8 18.1 100.0 635 Hanover 41.9 18.2 16.7 7.8 15.4 100.0 541 Westmoreland 32.2 20.8 18.3 12.5 16.3 100.0 621 St. Elizabeth 25.7 26.2 19.0 11.3 17.8 100.0 528 Manchester 31.2 16.3 18.7 13.7 20.2 100.0 668 Clarendon 28.1 18.9 16.0 14.5 22.6 100.0 649 St. Catherine 37.2 21.8 17.4 12.6 11.1 100.0 556 Age group 15–19 89.2 9.6 1.1 0.1 0.0 100.0 1,229 20–24 47.6 36.7 11.9 3.2 0.7 100.0 1,114 25–29 24.5 33.5 25.4 9.8 6.8 100.0 1,350 30–34 14.3 25.1 24.2 18.1 18.4 100.0 1,219 35–39 9.7 17.3 23.6 22.4 26.9 100.0 1,221 40–44 7.0 11.6 23.8 19.9 37.7 100.0 1,084 45–49 7.8 11.2 20.2 19.8 41.0 100.0 1,042 Current relationship status Married 8.2 15.7 30.5 20.8 24.8 100.0 1,441 Common law union 14.4 25.2 23.1 15.8 21.5 100.0 2,158 Visiting relationship 29.1 30.4 17.1 9.5 13.9 100.0 2,279 No steady relationship 61.8 13.1 8.3 7.7 9.0 100.0 2,381 Education level (in years)* 0–9 24.3 10.0 15.3 15.8 34.6 100.0 2,183 10–12 33.5 24.9 18.6 11.4 11.6 100.0 5,078 13 or more 45.3 25.5 17.2 8.7 3.3 100.0 995 Wealth quintile Lowest 21.4 15.0 17.2 13.4 32.9 100.0 2,001 Second 26.8 20.5 17.5 16.1 19.1 100.0 1,716 Middle 30.9 22.6 19.3 12.7 14.4 100.0 1,668 Fourth 40.3 26.1 15.6 10.0 7.9 100.0 1,650 Highest 45.6 23.8 18.7 8.1 3.9 100.0 1,224 *Excludes 3 women with missing information. Table 2.7A Number of Children Born Alive among Women Aged 15–49 Years by Selected Characteristics Reproductive Health Survey: Jamaica, 2008 Characteristic No. of Children Born Alive Total No. of Cases 36 Reproductive Health Survey, Jamaica 2008 0 1 2 or More Total 93.3 5.1 1.6 100.0 2,772 Residence Kingston Metropolitan Area 92.1 6.5 1.3 100.0 379 Other urban 93.3 3.9 2.8 100.0 759 Rural 93.6 5.4 0.9 100.0 1,634 Health region 1 93.2 4.4 2.4 100.0 788 2 92.0 6.3 1.7 100.0 552 3 93.5 5.0 1.6 100.0 774 4 94.0 5.6 0.4 100.0 658 Parish Kingston 91.4 7.0 1.6 100.0 209 St. Andrew 91.7 7.2 1.0 100.0 200 St. Thomas 92.2 4.9 2.9 100.0 212 Portland 94.5 4.5 1.0 100.0 182 St. Mary 86.7 10.1 3.2 100.0 186 St. Ann 95.0 4.2 0.8 100.0 184 Trelawny 91.9 6.7 1.4 100.0 169 St. James 93.5 5.1 1.4 100.0 215 Hanover 91.1 5.4 3.5 100.0 181 Westmoreland 95.2 3.9 0.9 100.0 209 St. Elizabeth 96.4 3.6 0.0 100.0 216 Manchester 91.6 8.1 0.4 100.0 236 Clarendon 94.5 4.7 0.8 100.0 206 St. Catherine 95.3 0.8 3.9 100.0 167 Age group 15–19 99.0 0.9 0.0 100.0 1,652 20–24 84.9 11.2 3.9 100.0 1,120 Current relationship status Married/common law union 47.1 33.0 20.0 100.0 161 Visiting relationship 85.6 12.6 1.8 100.0 552 Girlfriend with sex 98.0 1.7 0.3 100.0 829 Girlfriend without sex 99.9 0.1 0.0 100.0 410 No steady relationship 98.9 0.8 0.3 100.0 820 Education level (in years)* 0–9 96.5 2.9 0.6 100.0 686 10–12 92.4 5.5 2.0 100.0 1,942 13 or more 89.9 9.9 0.2 100.0 130 Wealth quintile Lowest 94.3 4.5 1.2 100.0 631 Second 93.7 5.4 0.9 100.0 619 Middle 91.5 5.2 3.3 100.0 512 Fourth 92.0 6.4 1.7 100.0 538 Highest 95.2 4.1 0.7 100.0 472 *Excludes 14 men with missing information. Table 2.7B Number of Children Born Alive among Men Aged 15–24 Years by Selected Characteristics Reproductive Health Survey: Jamaica, 2008 Characteristic No. of Children Born Alive Total No. of Cases Chapter 3: Fertility and Fertility-Related Factors 37 Chapter 3 Fertility and Fertility-Related Factors One objective of the RHS was to assess current levels and trends of fertility and pregnancy experiences and to identify factors that might influence reproductive behaviors. To obtain information about reproductive patterns, the survey included detailed information about childbearing, pregnancies resulting in other outcomes, the planning status of all pregnancies in the last five years, and desired family size and fertility preferences. All survey-based statistics regarding pregnancy experiences were derived from a complete lifetime pregnancy history, which consisted of information about all births, stillbirths, abortions, and other fetal losses. For each pregnancy event, the result of the pregnancy, the month and year of pregnancy outcome, and the duration were recorded. Information was collected about the most recent completed pregnancy, then the next-to-last, etc. For each live birth, information was collected on the sex of the child, survival status of the child, and age at death if the child did not survive. Information was also collected as to whether the woman was pregnant at the time of the survey, the gestational age of the current pregnancy, and the planning status at the time of becoming pregnant with the current pregnancy. Information was also collected on the proximate determinants of fertility, including: onset of menstruation, sexual experience and sexual activity, age at first marriage (union), durations of postpartum amenorrhea and postpartum abstinence, both of which affect the length of time a woman is insusceptible to pregnancy, and the onset of menopause. Except for the use of family planning methods (presented in Chapter 6), this chapter addresses all of the determinants that are largely responsible for the length and intensity of exposure to the risk of pregnancy. 3.1 Fertility Levels, Trends, and Differentials Traditionally, fertility analyses using Jamaican RHS data have been performed in terms of age-specific and total fertility rates (Table 3.1.1). The total fertility rate (TFR) is computed by accumulating the age-specific fertility rates (ASFRs) in each age group and multiplying the sum by five (the number of year-exposures in each group). The TFR is thus defined as the average number of live births a woman would have during her reproductive lifetime (age 15–49 years) if she experienced the currently observed ASFRs. Numerators for the ASFRs were calculated by selecting live births that occurred during 2-year periods preceding the survey and grouping them (in 5-year age groups) by the age of the mother at the time of pregnancy outcome (calculated from the mother’s reported date of birth). ASFR denominators represent the number of 38 Reproductive Health Survey, Jamaica 2008 woman-years lived by mothers in each specified 5-year age group during the same 2-year period. The TFR of 2.4 births per woman in Jamaica for 2006–2008 was lower than in the previous RHS surveys, but still above the replacement level fertility level of 2.1 births per woman (Figure 3.1.1). The interpretation of this figure is that, on average, a woman in Jamaica who is at the beginning of her childbearing years will have 2.4 children by the end of her reproductive period if fertility levels remain constant at the level observed in the 2-year period preceding the survey. Figure 3.1.1 Total Fertility Rates in Jamaica, 1975–2008 2.4 3.5 2.8 2.5 3.02.9 4.5 0 1 2 3 4 5 1973–1975 1981–1983 1987–1989 1991–1993 1995–1997 2000–2002 2006–2008 B ir th s p e r W o m a n Replacement Level ASFRs for the period 2006–2008 are also shown in Table 3.1.1 and Figure 3.1.2. Jamaican women initiate childbearing at an early age; the highest fertility levels are among 20- to 24-year-old, 25- to 29-year-old, and 30- to 34-year-old women, accounting for 26%, 19.8% and 20.2%, respectively, of the TFR. Fertility among adolescent women (72 births per 1,000 women aged 15–19 years) is the fourth highest, contributing 15% to the TFR. Women aged 35–39 and 40–44 make smaller contributions to total fertility; their ASFRs account for only 11% and 7%, respectively, of overall fertility. Using data from fertility, contraceptive prevalence and reproductive health surveys, age-specific fertility trends in Jamaica can be compared across seven 2-year periods (Table 3.1.1 and Figure 3.1.2). Compared to rates during the previous 2-year period (2000–2002), fertility declines in 2006–2008 were hardly significant. The only notable decline was in the 25–29 age-group, a 20% decline. There was a 9% decline in adolescent fertility, practically no change in fertility of women aged 20–24 years, and a slight increase in the fertility of women aged 30–34 years. The Chapter 3: Fertility and Fertility-Related Factors 39 changes in fertility among women aged 35 or older, whose contribution to the overall fertility is low, has been uneven. Figure 3.1.2 Age-Specific Fertility Rates for Seven Time Periods All Women Aged 15–49 Years: Jamaica 1975–2008 Looking back beyond the most recent 2 surveys, however, the changes in fertility have been substantial and driven almost exclusively by fertility declines among young women. Between 1983 and 2008, for example, the adolescent fertility rate had dropped by 41% and fertility of women aged 20–24 and 25–29 declined by 35% and 29%, respectively. From these point estimates, it can reasonably be concluded that most of the young women’s fertility rates declined in the 1980s, plateaued in the early and mid-1990s, after which they started to drop again at a much slower pace into the early and mid-2000s. As shown in Table 3.1.2, fertility among women living in Kingston Metropolitan Area (1.9 births per woman) and other urban areas (2.3 births per woman) was substantially lower than among rural-dwelling women (2.7 births per woman) in the 2-year period preceding the interview. Fertility was higher among rural residents at any given ages, except among women aged 40–44 years. Most of the difference between rural and urban fertility rates was due to higher ASFRs among rural residents aged 20–24 years and, to a lesser extent, to higher rates among women aged 25–34 years. By region, fertility rates were the lowest in Health Region 1, which includes Kingston (2.1 births per woman); fertility was the highest in Health Region 4 (2.7 births per woman. The highest adolescent ASFR was reported by residents of the St. James and Westmoreland parishes, which are included in Health Region 3 (121 and 116 births per 1,000 women aged 15–19, respectively). 40 Reproductive Health Survey, Jamaica 2008 In accordance with patterns observed in most other countries, a large negative association between fertility and education was observed. The TFR among the highest educated women was less than half the level observed among women with the lowest education attainment (1.6 vs. 3.4 births per woman). Fertility differences according to education were more pronounced among younger women. Generally, peak fertility occurred at ages 30–34 among women with the highest educational attainment, whereas peak fertility among women with lower educational levels occurred at ages 20–24. The largest fertility gap was observed between adolescent women with the highest education levels, whose fertility was 12 times lower than of those with only 0–9 years of schooling (12 vs. 140 births per 1,000), Similarly, a negative association between wealth and fertility was observed—women living in households within the two wealthiest quintiles reported half of the fertility rates of women in the poorest households (1.8 and 1.3 births per woman, respectively, vs. 3.5 births per woman) (Figure 3.1.3). Having the lowest household wealth was associated with the highest rates among the ASFRs that contribute the most to the total fertility rate. Figure 3.1.3 Two-Year-Period Age-Specific Fertility Rates by the Wealth Quintile of the Household: Jamaica, 2008 Table 3.1.3 examines the extent of childlessness by current age in Jamaica. Overall, 33.0% of women in 2008 reported they have never given birth. As expected, the percentage of childless women decreases with increasing age, because of longer exposure to the risk of pregnancy. Women living in the Kingston Metropolitan Area (37.7%) were more likely to report childlessness than rural women (30.6%) at any given age group. Within each age group, the percentage of childless women also rose with the number of years of schooling and the wealth status of the household. Generally, the percentages fell with decreasing frequency of attendance at church services and this effect was observed in most age groups. Chapter 3: Fertility and Fertility-Related Factors 41 3.2 Teenage Pregnancy Teenage pregnancy rates, defined as the sum of live births, abortions, and fetal deaths per 1000 women aged 15–19 years, are an important public health problem in Jamaica. Because data on abortions and miscarriages are underreported in surveys, most of what is known about adolescent pregnancy in Jamaica is limited to teenage births. Adolescent mothers are more likely to have unintended pregnancies, low use of antenatal health care services, low birth weight, prematurity, and complications during labor and postpartum, which lead to higher morbidity and mortality for themselves and their children. Given their high rates of unintendedness, it is likely that some adolescents may terminate a pregnancy before term. Preventing teenage pregnancy through education, behavioral change, and quality services for youths has been one of the priority areas of focus for the Jamaican family planning program and donor agencies. Table 3.2 shows the percentage of women age 15–19 who were pregnant with their first pregnancy at the time of the RHS, the percentage who reported they had at least one completed pregnancy at the time of the interview, and the percentage who initiated motherhood (i.e. had at least one live birth). It is important to note these rates were calculated among the entire population of adolescent women and represent conservative estimates. First, some women who had pregnancies that ended in induced abortion choose to omit these outcomes for fear of self-incrimination; second, some adolescents who had never been in union may have not reported sexual debut; and third, some teens, especially those very young, were not sexually experienced and therefore not at risk of becoming pregnant, but they were included in the denominators of the rates. Overall, 14.6% of adolescent women have ever been pregnant, including 2.9% who were currently pregnant for the first time. About one in ten (10.8%) teenagers has already given birth. As expected, the proportion of young women who have ever been pregnant or have ever gave birth increases rapidly with age, from 4.0% and 1.7%, respectively, among women aged 15, to 9.1% and 4.2%, respectively, of women aged 17, and to 29.5% and 24.8%, respectively, of women age 19. The same factors that influence higher fertility rates in general have been associated with higher rates of pregnancy among teenagers. With regards to residence, about twice as many young women in rural areas or in urban areas than in Kingston Metropolitan Area have begun childbearing. Teenagers in the Health Region 3 reported the highest pregnancy and fertility rates. The proportion of teenage pregnancy decreased significantly with educational attainment, and the wealth status of the households; teenagers in the highest wealth quintiles were the least likely to have ever been pregnant or have a child during their teenage years. It is worth noting that the proportion of adolescents who reported ever having had sexual intercourse had declined for both women and men (see also Chapter 12). Further, the rates of 42 Reproductive Health Survey, Jamaica 2008 contraceptive use (mostly condoms) among sexually active teens had increased. Despite these trends, one in seven young women had at least one pregnancy before reaching the age of 20. 3.3 Age at Menarche and Sexual Experience The age at menarche (first menstruation) has a positive effect on fertility since it represents the beginning of the time interval during which women could become pregnant. All women were asked “how old were [they] when the first period started;” this information was used to calculate the mean age at menarche. In Jamaica, like elsewhere, the average age at first menstrual period had gradually declined in recent times by more than one year, from age 14 in 1989, to age 13.2 in 1997, to age 12.9 in 2002. Most theories recognize that the downward trend in the age at first menstrual period is multi-factorial, with heredity, improvements in nutrition, and better health status being among the most important factors. Table 3.3.1 and Figure 3.3.1 show the mean age at which Jamaican women had started to menstruate, classified by the current age. Comparisons with results from previous reproductive health and contraceptive prevalence surveys show a substantial decline in the mean age at menarche between 1989 and 2008 among all age cohorts. Further, among women interviewed at the same point in time, older cohorts consistently exhibit older ages at menarche than younger cohorts. Figure 3.3.1 Mean Age at First Menstrual Period by Age Cohort Jamaica, 1989–2008 Similar to previous surveys, the age of onset of puberty in 2008 was associated with the level of education and the socio-economic status of the household, probably because better living Chapter 3: Fertility and Fertility-Related Factors 43 conditions, proper nutrition, smaller families and improved general health associated with higher education and wealth levels may induce an earlier growth spurt. In addition, younger women tend to stay longer in school and younger cohorts reported lower age at menarche in all surveys. Early menarche had been associated with early dating onset and early sexual debut. Encouragingly, despite the declining mean age of menarche in Jamaica, there is a recent shift toward postponement of the age at first intercourse among adolescent girls, particularly among those ages 15–17 years, indirectly reflected in the proportion of sexually experienced teenagers (Figure 3.3.2). 44 38 32 26 80 72 73 72 0 20 40 60 80 100 1993 1997 2002 2008 Survey Year P e rc e n ta g e Women 15–17 years Women 18–19 years Figure 3.3.2 Reported Sexual Experience among Young Women Aged 15–17 and 18–19 Years: Jamaica, 1993–2008 Since the age at first intercourse is correlated with age at first pregnancy, it had been suggested that age at menarche is therefore correlated with age at first pregnancy. Thus, it is useful to think of the average age at the first menstrual period as an indicator of the probability of early intercourse and early childbearing and to initiate sex education activities prior to the timing of menarche in a population. One of the objectives of the RHS was to explore young adults’ opinion about the best age to start sex education (Table 3.3.2). Virtually all young women agreed that courses on family life and sexual education should be taught in school and the majority (77.4%) stated the best age to start teaching these topics is age 12 or younger. Respondents who favored the early (before age 12) onset of school-based courses were slightly more likely to reside in Health Region 3 (86.8%), including Westmoreland and St. James parishes (90.2% and 87.5%, respectively), to be older, and to live in households with the highest wealth status. 44 Reproductive Health Survey, Jamaica 2008 The overall proportion of women who reported sexual experience did not change significantly in the last decade: 87.6% in 1997, 88.8% in 2002 and 87.3% in 2008 (data not shown). As expected, sexual experience increased directly with age, since older women have a longer time of exposure, and declined slightly with the increase in the wealth status of the household (Table 3.3.3). Sexual experience was inversely correlated with the frequency of church attendance; that is, women who attended church at least weekly were the least likely to report sexual experience. Reports of sexual experience rose as attendance became less frequent. 3.4 Age at First Intercourse, Union, and Birth Age at first sexual intercourse and first union play an important role in determining fertility. Delays in these events decrease the number of reproductive years that a woman spends at risk of getting pregnant, and increase the likelihood of having fewer children. Age at first birth also has a direct impact on fertility because postponing the first birth may contribute to the decline of the TFR. Information on age at first sexual intercourse, first union, and first live birth for all women are presented by age of the respondent at the time of interview in Table 3.4.1. The left side of the table shows the proportion of respondents within each 5-year age cohort who have ever had sexual intercourse (top panel), ever been in formal or consensual union (middle panel), and ever had a live birth (bottom panel) before reaching specific ages. The overall median age (age by which 50% of women aged 15–49 have experienced the event) and the median age within each age group are displayed for each event in the right side of the table. By comparing the proportion of women within different cohorts who experienced various events before age 20, it is possible to detect whether the average age of occurrence of each event has changed over time. For example, the proportion of women who had sexual intercourse before age 20 has increased from 80% among 40- to 49-year-olds to 86% among 20- to 24-year-olds and the proportion reporting entry into a union before age 20 had increased from 58–59% to 80%, respectively. As a result, the median age at first intercourse had decreased by 0.6 year and the median age at first union had decreased by more than one year between the oldest and the youngest cohorts. Thus, the gap between the median age at first intercourse and first marriage has narrowed by decreasing the latter more rapidly than the former (Table 3.4.1 and Figure 3.4.1). The changes in the onset of childbearing were less consistent among cohorts, but fewer women aged 20–24 and 25–29 years have given birth prior to age 20 than among older cohorts and their median age at first birth was almost one year older than among women aged 40–49 years. Among the youngest cohort, the increase in the proportion of women who married before age 20 and the decline in the proportion who gave birth by the same age has important implications for future fertility patterns and fertility control measures. The youngest Jamaican women tend to have earlier sexual debut, earlier entry in a union relationship, but a relatively later start (2–3 Chapter 3: Fertility and Fertility-Related Factors 45 years after the first marriage) of childbearing than older cohorts. As a result, their contraceptive needs are likely to be greater and their fertility will reach the highest levels at older ages during their reproductive years. Compared with their counterparts in older cohorts, they will spend a 80 58 42 86 80 848386 80 73 67 66 59 48 4443 34 38 0 20 40 60 80 100 20–24 25–29 30–34 35–39 40–44 45–49 Survey Year P e rc e n ta g e First Sex First Union First Birth Figure 3.4.1 Percentage of Women Aged 20–49 Years Who Had Sexual Debut, First Union, and First Birth before Age 20: Jamaica, 2008 slightly shorter time at risk of premarital pregnancy but a longer time between the first marriage and first birth; thus, they will have a greater need for reversible, effective contraception, such as injectables and oral contraceptives. In 2008, the median ages at first sexual experience and first union among all women aged 15–49 years were 17.1 and 18.3, respectively (Table 3.4.1 and Figure 3.4.2), similar to the corresponding figures documented by the 2002 survey. This corroborates the findings that the proportion of women who reported sexual experience or marital experience did not change significantly compared to 2002. Only the median age at first birth changed between 2002 and 2008, increasing by almost 0.5 year (from 20.7 to 21.2). Despite this increase, the onset of childbearing is still very early, consistent with the contribution of the young cohorts to current level of total fertility. 46 Reproductive Health Survey, Jamaica 2008 17.0 17.1 18.1 18.3 20.7 21.2 0 5 10 15 20 25 2002 2008 Y e a rs Median Age at First Sexual Experience Median Age at First Union Median Age at First Birth Figure 3.4.2 Median Age at First Sexual Experience and First Birth among Women Aged 15–49 Years: Jamaica, 2002 and 2008 Reported median age at first birth correlates well with the prevailing opinion expressed by 48.4% of women that the best age to start childbearing is between 20-24 years (Table 3.4.2). 3.5 Recent Sexual Activity Information about sexual activity was collected for all women and young men who had sexual relations. These include the timing of the last intercourse, average number of sexual partners, and patterns of condom use during the last 12 months and lifetime. In addition, more details were collected from respondents who had sexual intercourse in the last 12 months about their sexual encounters with the last, next-to-last, and second-to last partners: relationship with the sexual partner, use of a primary and secondary method of contraception, and use of alcohol or recreational drugs with each partner. This section includes selected results related to the current and recent sexual activity. More data are related to sexual behaviors are included in Chapters 12 and 13. Current sexual activity is an essential indicator for estimating the proportion of women who are at risk of becoming pregnant (including the risk of having an unintended pregnancy), and who may require contraceptive services. It also has major implications for the selection of a contraceptive method that best suits the sexual and reproductive behaviors and fertility preferences of each individual. Thus, the patterns of sexual activity are taken into account in estimating the proportion of women in need of family planning services and their contraceptive choices, presented in Chapter 10. Chapter 3: Fertility and Fertility-Related Factors 47 As was shown in Table 3.3.3, 87.3% of all women aged 15–49 who were interviewed in the 2008 RHS were sexually experienced. The corresponding proportion among young men aged 15-24 was 74.9% (see also Chapter 12). However, not all women and men who were sexually experienced were currently sexually active (i.e., had had intercourse in the month preceding the interview): only 62.4% of women and 51.6% of young men reported current sexual activity (Table 3.5.1). As expected, the level of current sexual activity was influenced by the existing type of union relationship, with higher levels reported by women and men in more stable unions and lower levels among those in less stable relations. Among women who were married or living with a common-law partner, about 90% reported having had intercourse at least once within the past month. The corresponding proportion among young men was very similar. Further, 81.4% of women and 90.3% of young men in a visiting relationship —that is a relationship in which the partners do not share the household—reported sexual activity in the month prior to the survey. The proportion of currently sexually active women and young men who were in a sexual relationship with a boyfriend or girlfriend was somewhat lower (64.6% and 77.8%, respectively). Only 3.8% of women and 11.3% of young men who did not have a steady relationship (many of them not sexually experienced) reported having had sexual experience in the month preceding the interview. Compared to previous surveys, the proportion of currently sexually active women and young men had increased. Among women, it increased from about one in two women who reported current sexual experience in 1997 to almost two in three women (Table 3.5.1 and Figure 3.5.1). Figure 3.5.1 Current Sexual Activity by Current Relationship Status among Women Aged 15–49 Years: Jamaica, 1997–2008 * Sexual activity with a boyfriend or date was not covered in the 2002 RHS. 53 82 80 66 54 3 54 86 83 66 62 91 90 81 65 4 0 20 40 60 80 100 Total Married Common law union Visiting relationship Boyfriend with sex No steady relationship 1997 2002* 2008 48 Reproductive Health Survey, Jamaica 2008 The increase was noticeable among women in each type of union relationship, but was the highest among women in a visiting partner relationship (from 66% in 1997 and 2002, to 81% in 2008). A similar pattern was observed among young men in a visiting partner relationship (from 75% in 1997, to 69% in 2002 and 78% in 2008). The current levels of sexual activity among young adults are more appropriate for estimating the current risk of unintended pregnancy, risk of contracting sexually transmitted diseases, and contraceptive needs than the levels of sexual experience. As shown in Figure 3.5.2, about 2 in 3 young adult women (i.e., those aged 15–24) and 3 in 4 young adult men reported they have ever had sexual intercourse; 48% and 52%, respectively, reported their last sexual encounter within the past 30 days, and 7%–9% within the past 1–3 months. Figure 3.5.2 Timing of the Last Sexual Intercourse among Young Adult Women and Men Aged 15–24 Years: Jamaica, 2008 25 52 9 14 Women 15–24 Men 15–24 34 48 7 11 Past 30 Days 1–3 Months Ago >3 Months Ago No Experience Despite a recent decline in the proportion of adolescent girls and boys aged 15–19 years who had initiated sexual intercourse—from a high of 58.9% and 74.5%, respectively, in 1993 to a low of 43.6% and 61.5%, respectively in 2008, as shown later in Chapter 12, Table 12.2.1—the current levels of sexual activity among sexually experienced youths, and implicit exposure to the risk of pregnancy and STIs, have actually increased (Table 3.5.2 and Figure 3.5.3). These changes seem to be independent of changes in the union relationships. For example, the proportion of adolescent women in a married, common-law, or visiting partner relationship had actually declined between 2002 and 2008 (from 35.5% to 25.8%), whereas the proportion of 20- to 24-year-olds in such relationships had increased (from 68.6% to 77.5%). Among young adult men, the proportion in more stable union relationships had significantly declined for both 15– Chapter 3: Fertility and Fertility-Related Factors 49 19-year-olds and 20–24-year-olds, from 33.6% to 10.1% and 62.9% to 49.1%, respectively (data not shown). 57% 81% 42%41% 66% 70% 1997 2002 2008 62% 79% 48%50% 60%61% 1997 2002 2008  15–19-year-olds  20–24-year-olds Women Men Figure 3.5.3 Trends in the Current Sexual Activity among Sexually Experienced Women and Men Aged 15–19 and 20–24 Years: Jamaica, 1997–2008 Except for the influence of current age and relationship status, the current sexual activity varies little by other background characteristics (Table 3.5.2). Table 3.5.3A shows the relationship status of the last sexual partner by the current union relationship status among sexually experienced women aged 15–49 years. As in previous surveys, virtually all women in a legal or consensual marriage reported their last sexual intercourse was with their husband. A slightly lower percentage (93.4%) of those in visiting unions had their last sexual intercourse with a visiting partner. Similarly, the majority of women currently in a sexual relation with a boyfriend reported the last intercourse was with a boyfriend. Very few (6.5%) said their last intercourse was with a visiting partner, presumably a former partner or a misclassification of the relationship at the last sexual intercourse. Sexually experienced women not currently in a steady relationship reported various relations with their last sexual partners. Most reported their last intercourse with a former visiting partner (39%) or former husband/common-law partner (23%); about one in five (22.4%) reported last intercourse with a boyfriend; and 15.7% reported last intercourse with a more casual partner. Relationship status of the last sexual partner by the current union relationship status among sexually experienced young men is shown in Table 3.5.3B. Tables 3.5.4 and 3.5.5 present the relationship status of the last sexual partner among sexually experienced women aged 15–49 years by other background characteristics. Because typically women tend to report current sexual relations with their current partners, as shown in the 50 Reproductive Health Survey, Jamaica 2008 previous table, the patterns of their relationships by background characteristics greatly resemble the patterns of the union relationship status. Older women, particularly those aged 40 years or older, were more likely to report the last sexual encounter with a husband, whereas younger women were more likely to have had the last intercourse with a visiting partner or a boyfriend. Boyfriend-girlfriend relationship at the last intercourse was most common among women aged 15–19 years. Differentials in stable relationships with the last sexual partners did not vary greatly by education and wealth status, but women with the highest education level and those with the highest wealth status were slightly more likely to report the last intercourse with a boyfriend. Table 3.5.6 shows the percentage of sexually experienced women who were not currently sexually active but had sexual relations 1–3 months ago. Overall, fewer women in 2008 than in 2002 or 1997 had intercourse 1–3 months ago (17% vs. 38.7% and 35.4%, respectively), ranging from 48.3% among women in common-law unions to 6.1% among those not in steady relationships. 3.6 Postpartum Amenorrhea, Abstinence and Insusceptibility Postpartum amenorrhea is defined as the period between the termination of conception, regardless of its outcome, and the return of ovulation, generally approximated by the resumption of menstruation following childbirth. This period depends on a number of biological and sociodemographic factors which vary considerably among women, including the duration and intensity of breastfeeding, age, parity, and nutritional status. Because the fecundability of the woman (i.e., risk of conception) in this period is very low, it is a major contributor to the postpartum insusceptibility. The other main determinant of the insusceptible period is the duration of the sexual abstinence following the termination of conception. Thus, women are considered postpartum insusceptible if they either are postpartum amenorrheic or they had not resumed sexual activity following a pregnancy. Table 3.6.1 shows the percent of women with a birth in the last 24 months for whom period had not returned, and who had not resumed sexual relations by time since the birth. It also shows proportions insusceptible, meaning that either their period had not returned or they had not resumed sexual activity. The majority of women were classified as being insusceptible to pregnancy within the first 2 months following childbirth, because of both postpartum amenorrhea and postpartum abstinence. After the second month, the contribution of amenorrhea was greatly reduced and more women were sexually abstinent than amenorrheic (45.4% vs. 30%). Sexual abstinence declined rapidly after the fourth month while the decline in postpartum abstinence was more gradual. At 7–8 months after birth, almost 1 in 4 mothers were still amenorrheic and equal proportions were abstaining. At 11–12 months postpartum, the proportion amenorrheic was only 13% and very few women (6.1%) were abstaining. Chapter 3: Fertility and Fertility-Related Factors 51 The proportion of women amenorrheic, abstinent, or insusceptible, classified by time since birth can be used to calculate a “current status” mean duration of each of these states. The mean duration of amenorrhea was 3.1 months; of abstinence, 4.4 months; and insusceptibility, 4.8 months. Thus, the length of the period of insusceptibility appears to be more influenced by the duration of postpartum abstinence than by the duration of amenorrhea. This is likely due to changes in the duration and intensity of breastfeeding, but the information on breastfeeding was not collected in the 2008 survey. The changes in resuming sexual intercourse after birth have been less pronounced. 5.6 5.6 3.1 6.8 4.8 4.4 8.7 6.2 4.8 0 2 4 6 8 10 1997 2002 2008 M o n th s Postpartum Amenorrhea Postpartum Abstinence Postpartum Insusceptibility Figure 3.6.1 Trends in the Mean Duration of Postpartum Amenorrhea, Abstinence and Insusceptibility after the Most Recent Live Birth in the Last 24 Months among Women Aged 15–49 Years: Jamaica, 1997–2008 Compared to previous surveys, there was a notable drop in the mean duration of postpartum insusceptibility in 2008, thanks to a sharp decline in the average duration of postpartum amenorrhea (from 5.6 months in 1997 and 2002 to 3.1 months in 2008) and a more gradual decline in the mean duration of abstinence (Figure 3.6.1). Table 3.6.2 shows proportions of women with a birth in the last 24 months classified as postpartum amenorrheic, abstinent and insusceptible. Almost identical proportions of women reported postpartum amenorrhea and abstinence (20.9% and 20.4%, respectively) and almost 1 in 3 women (30.8%) were postpartum insusceptible. The proportion of women who reported postpartum amenorrhea, abstinence, and insusceptibility at the time of the interview varied greatly within subgroups. Postpartum amenorrhea, for example, was more prevalent among residents of Health Region 4 (24.4%), among the least educated women (some of them very young), and among women with intermediate to high wealth status. The lowest prevalence, presumably related to a short duration of breastfeeding, was reported by women with the highest wealth status (9.3%). 52 Reproductive Health Survey, Jamaica 2008 The percent distribution of women with live births in the period 2003 to 2008 by the duration of postpartum abstinence is shown in Table 3.6.3. Overall, 28.2% of women reported durations longer than 5 months (i.e. 20 weeks). Slightly shorter durations were reported by women residing in Health Region 2, St. Ann parish, those aged 15–19 years, those with the highest number of years of schooling, and those with the two highest wealth quintiles. The effects of postpartum abstinence and amenorrhea combined—postpartum insusceptibility —could account for important increases in the time between births (i.e. birth spacing). Promoting birth spacing has long been a central goal of the family planning program in Jamaica. Since lactation and amenorrhea can be important contributors to delaying subsequent conception, promoting consistent and prolonged breastfeeding is useful in developing biological interventions for family planning and maternal and child health care programs. At the same time, family planning providers should be aware of the potential need to switch women who breastfeed to different methods after giving birth. Offering accurate information about the benefits of spacing, along with a wide variety of contraceptive methods including the Lactation Amenorrhea Method (LAM), will help women space their births longer. As such, it is important to examine the current level of support for prolonged breastfeeding, which may predict future contraceptive needs and inform effective birth spacing messages. Overall, only 25% of women aged 15–49 years were in favour of a long duration of breastfeeding; 12.4% supported durations of 1 year or more, and 12.6% said that “as long as possible” is ideal (Table 3.6.4). The support for long breastfeeding duration was slightly higher among rural residents, residents of Health Region 2, women aged 35 years or older, women with less than a post high-school education, and women residing in households with low and middle wealth status. The opinions of respondents about the ideal breastfeeding duration in 2008 have changed significantly since 1993 (Figure 3.6.2). In 1993 and 1997, a far larger proportion of women aged 15-49 expressed the view that the ideal duration of breastfeeding is more than 1 year (38% and 36%, respectively), whereas only 12–13% of women in 2002 and 2008 believed so. Conversely, only about one in 10 women in 1993 and 1997 said that 1-6 months was an ideal duration, compared to 1 in 4 and 1 in 3, respectively, in 2002 and 2008. Chapter 3: Fertility and Fertility-Related Factors 53 12 9 26 35 36 34 42 36 38 36 13 12 10 14 14 13 0% 20% 40% 60% 80% 100% 1993 1997 2002 2008 1–6 months 7–12 months More than 1 year As long as possible Figure 3.6.2 Opinions about the Ideal Duration of Breastfeeding among Women Aged 15–49 Years: Jamaica, 1993–2008 3.7 Planning Status of the Last Pregnancy Accurate documentation of reproductive intentions is important for understanding a population’s fertility rates, fertility-related behaviors, and contraception needs. Based on existing literature, unintended pregnancy has been associated with the use of elective abortion, inadequate prenatal care, unfavorable maternal behaviors, and pregnancy or perinatal complications. Conventional measures of unintended pregnancy are designed to reflect a woman's intentions before she became pregnant. Thus, for current pregnancies and pregnancies ended since January 2003, all respondents were asked about the pregnancy planning status at the time of conception. Each completed or ongoing pregnancy was classified as either planned or intended (i.e., wanted at the time it occurred), mistimed (i.e., occurred earlier than desired), unwanted (i.e., occurred when no children, or no more children, were desired), or unsure. Mistimed and unwanted pregnancies together constitute “unplanned” (unintended) pregnancies (Figure 3.7). 54 Reproductive Health Survey, Jamaica 2008 Figure 3.7.1 Demographic Terminology for Pregnancy Intentions Wanted Planned Mistimed Unwanted (Intended) Unplanned (Unintended) Note: Planning status was reported at the time of getting pregnant with the last pregnancy, occurred in the last five years, and includes the planning status of current pregnancies. Reliable information on pregnancy intentions, however, is difficult to collect. One common problem is the underreporting of pregnancies that ended in induced abortions. Because the majority of these pregnancies are mistimed or unwanted, unplanned pregnancies will be underreported to the extent that abortions are underreported. In this report, unintended pregnancy estimates include only births and current pregnancies. Another problem with accurate depiction of unwanted pregnancies might be the retrospective rationalization and ambivalence about pregnancy intention when the outcome is a live birth. Compared to self- assessments of pregnancy intention at the time of conception, retrospectively reported intentions after the child is born tend to be more positive. Thus, the data presented here represent conservative estimates of the true levels of unplanned pregnancies. The proportion of pregnancies in Jamaica that were reported as unplanned was quite high (Table 3.7 and Figure 3.7.2). In 2008, 50% of women reported their last or current pregnancy as planned and 47% said it was unplanned, including 15.9% who reported it as unwanted. About two-thirds of unplanned pregnancies were mistimed pregnancies. A small proportion of women (3.3%) were unsure about the planning status of their last pregnancy. Chapter 3: Fertility and Fertility-Related Factors 55 Not Wanted 16% Not Intended 47% Intended 50% Mistimed 31% Figure 3.7.2 Planning Status of the Last Pregnancy among Women Aged 15–49 Who Were Currently Pregnant or Gave Birth in the Last 5 Years: Jamaica, 2008 Not Sure 3% However, fewer women reported they experienced unplanned pregnancies in 2008, compared to any other previous survey year (47% in 2008 vs. 58% in 2002, 61% in 1997, 67% in 1993, and 72% in 1989)(Figure 3.7.3). Thus, the proportion of unintended pregnancies in Jamaica has declined by 35% between 1989 and 2008. The largest drop occurred between 2002 and 2008 (a 19% decline), primarily due to a steep decline in the mistimed pregnancies (from 42% to 31%). Overall, 45.6% of the women who had a live birth in the last 5 years reported that conception as unplanned (Table 3.7). Among currently pregnant women the proportion with unplanned conceptions was higher (58.7%), indicating a greater lik

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