Russia Reproductive Health Survey 2011

Publication date: 2011

Reproductive Health Survey Russia 2011 Executive Summary REPRODUCTIVE HEALTH SURVEY RUSSIA 2011 EXECUTIVE SUMMARY Federal State Statistic Service (ROSSTAT) Ministry of Health of the Russian Federation Information and Publishing Center “Statistics of Russia” United Nations Population Fund (UNFPA) Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, USA (DRH/CDC) September, 2012 This summary report was funded by the United Nations Population Fund (UNFPA). ii Table of Contents Chapter 1: Introduction . 1 Chapter 2: Methodology. 4 Chapter 3: Characteristics of the Sample. 6 Chapter 4: Fertility. 7 Chapter 5: Induced Abortion . 10 Chapter 6: Maternal and Infant Health . 14 Chapter 7: Contraceptive Knowledge. 18 Chapter 8: Current and Past Contraceptive Use . 21 Chapter 9: Need for Contraceptive Services . 25 Chapter 10: Contraceptive Counseling. 27 Chapter 11: Opinions About Contraception . 29 Chapter 12: Reproductive Health Knowledge and Opinions. 32 Chapter 13: Women’s Health . 34 Chapter 14: Family Life Education. 37 Chapter 15: Young Adult Reproductive Health. 40 Chapter 16: Sexually Transmitted Infections Other Than HIV/AIDS . 43 Chapter 17: HIV / AIDS . 45 Chapter 18: Violence Against Women. 48 Chapter 19: Infertility . 51 iii iv Chapter 1: Introduction Chapter 1: Introduction 1.1 Background The status of women’s health in Russia is strongly influenced by cultural, historical, and socioeconomic factors. During the Soviet period and continuing into the post-Soviet era, fertility steadily declined to below-replacement levels. Historically, Russian women have tended to use both modern and traditional contraceptive methods extensively, but, at the same time, have depended heavily on the use of induced abortion as a means of preventing unintended births and achieving low fertility. Major changes in the organization of health care services and financing over the past several decades haves ushered in a long period of transition in which major reforms of different sectors have been carried out. Despite the growth of private practice hospitals and physicians in recent years, however, the Ministry of Health continues to be the primary provider of health care in the Russian Federation. In 2007, the Russian Federation adopted a Demographic Concept Policy for the Russian Federation 2025. Fundamental goals of the policy include at least 50% reduction of maternal and infant mortality and strengthening of population reproductive health. The following strategies are being adopted to achieve the goals: • Increase the availability and quality of free medical care to women during pregnancy and childbirth and to newborns through the development of family-oriented perinatal approaches, that reduce the risk of adverse outcomes of pregnancy and childbirth; • Strengthen the infrastructure and staffing for maternal and child services in accordance with existing standards for maternity care; and develop high-tech medical care for women during pregnancy and childbirth. • Ensure the availability and quality of reproductive health care, including assisted reproductive technologies and eliminating hazardous working conditions; • Strengthen preventive strategies to reduce unwanted pregnancies. The Russian Ministry of Health monitors reproductive health based on existing federal statistical surveillance systems and birth certificates. Several important limitations affect the usefulness of these data. Currently, official vital records are incomplete, due to missing data from institutions outside the Ministry of Health system. Existing data are also limited due to lack of information on quality of care. These data, as well as information about women who do not receive regular medical care, can be collected only through large sample surveys. Results from the Russia Reproductive Health Survey 2011 will provide data to inform all these goals in the area of reproductive health. Recent progress has been made in increasing women’s access to modern contraceptives and 1 Chapter 1: Introduction other reproductive health services, but many challenges remain, particularly in reaching the most vulnerable women and providing high- quality services. To help policymakers and program managers assess and respond to current needs, a national reproductive health survey was needed. Funding for the Russia Reproductive Health Survey 2011 (RURHS11) was primarily provided by two major international donors: the United Nations Population Fund (UNFPA), which covered all costs related to field work, translation, and dissemination seminars; and the United States Agency for International Development (USAID), which supported the CDC technical assistance for survey design, implementation, and dissemination. The survey was carried out by Russian agencies including the Federal State Statistic Service (ROSSTAT), the Ministry of Health, and IPC Statistics of Russia which worked together to coordinate survey activities and to design and carry out the fieldwork. Technical assistance in these activities was provided by the Division of Reproductive Health (DRH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA. 1.2 Objectives Periodic population-based household surveys are the best and most timely way to collect information on a wide assortment of health topics essential to determining the health status and needs of Russian families and women, as well as the types of health services they do or do not receive. Managers, decision-makers, and others from public health institutions, the private sector, and from multinational organizations such as UNFPA, have a great need for high quality information to design health services for women. The aim of the RURHS11 was to obtain national and regional estimates of basic demographic indicators in order to set targets, allocate resources, and monitor performance of family planning and maternal and child health programs. Specific objectives of the RURHS11 were:  to assess current levels and trends in fertility, abortion, contraception, and various other reproductive health indicators;  to enable policy makers, program managers, and researchers to evaluate existing reproductive health programs and develop new strategies;  to study factors that affect fertility, contraceptive use, and maternal and infant health, such as geographic and socio- demographic factors, breastfeeding patterns, use of induced abortion, and availability of family planning services;  to identify characteristics of women at increased risk of unintended pregnancy;  to identify subgroups at high risk for adverse reproductive health outcomes and help develop targeted interventions;  to obtain data on the knowledge, attitudes, and behavior of young adults aged 15–24 years;  to provide data on the level of reported sexually transmitted infection (STI) 2 Chapter 1: Introduction symptoms and knowledge about transmission and prevention of HIV/AIDS. By making available appropriate country- and region-specific data on reproductive health and services and enhancing the ability of national organizations to collect, analyze, and disseminate such information, the survey has fostered collaboration between the government and international partners. For example, UNFPA will use the survey data to monitor its strategic objectives in the context of the Russian health sector priorities. The survey can facilitate a better understanding of the linkages among health needs, health services, and health sector reforms and how they influence each other. Thus, the Russian Ministry of Health and other international partners (e.g., USAID and UN agencies) can use these data for developing new health strategies and health sector reforms and for monitoring and evaluating progress toward achieving the Millennium Development Goals (MDGs). 3 Chapter 2: Methodology Chapter 2: Methodology 2.1 Sampling Design The RURHS11 was based on in-person, face-to-face interviews with women of reproductive age (15–44 years) in their homes. The survey was designed to collect information from a representative sample of approximately 10,000 women of reproductive age throughout the Russian Federation. The universe from which the respondents were selected included all females between the ages of 15 and 44 years, regardless of marital status, who were living in households in Russia when the survey was carried out. Women living in some very sparsely populated regions and in areas where security was a problem were excluded, overall a very small proportion of Russia’s total population. 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 child health care utilization  Choice and quality of maternity care  Preventive and curative health care utilization  Perceptions of health service quality  Risky health behaviors (smoking and alcohol use)  Young adult health education and behaviors  Intimate partner violence  HIV/AIDS and other STDs The household survey had a stratified multistage sampling design using census sectors developed for the 2010 national census as the sampling frame. To better assist the key stakeholders in assessing the baseline situation at a sub-national level, the sample design was adapted to produce representative estimates for Moscow; other cities with a population of more than 1 million; other urban areas; and rural areas. Data are also representative for urban- rural distribution. The sample for the survey was selected in three stages: primary sampling units (PSU’s), households, and women of reproductive age. In preparation for the 2010 national census, the country was divided into sampling units, which constituted the primary sampling units (PSU’s) for the survey. The 60 subject areas of the Russian Federation that were included in the survey contained a total of 311,278 sampling units (229,977 in urban areas and 81,751 in the rural areas). From this sample frame 500 sampling units were selected, with probability proportional to size (365 from urban areas and 135 from rural areas). In the second stage, compact clusters of 40 households were randomly selected within each of the selected PSU’s. Finally, in each of the 40 households selected, one woman between the ages of 15 and 44 was selected at random for to participate in the individual survey. The total number of sampled households was designed to yield approximately 10,000 completed interviews, taking into account an anticipated number of unoccupied households and refusals to participate. 4 Chapter 2: Methodology 2.2 Data Collection Organization and conduct of data collection fieldwork was undertaken by the non-profit, private organization Information and Publishing Center (IPC) Statistics of Russia. IPC Statistics of Russia organized the training of 348 regional coordinators and female interviewers from the 60 subject areas of the Russian Federation. Training was conducted with the collaboration of ROSSTAT, national experts from various institutions including the Ministry of Health, UNFPA, and CDC. Fieldworkers conducted face-to-face interviews with sampled respondents, and field supervisors conducted follow-up visits to verify data quality. Once questionnaires were completed and checked they were sent to IPC Statistics of Russia for data entry. Data entry was performed centrally by ten data entry operators who were trained by CDC in the use of the data entry package CSPro. Technical support for data entry, as well as control of the process, was carried out by a Russian IT- specialist. 2.3 Response Rates Of the 21,229 households selected in the sample, 10,570 (50%) had at least one eligible respondent (women aged 15–44 years). Of these, completed interviews were obtained for 10,010 women, resulting in a response rate of 95%. Not surprisingly, Moscow had a comparatively low response rate of 84%, while the other three regions had response rates above 95%. 5 Chapter 3: Characteristics of the Sample Chapter 3: Characteristics of the Sample Overall, 32% of respondents were 15–24 years of age at the time of interview, 37% were 25-34, and the remaining 32% were 35-44. Almost half of respondents were currently legally married (49%), 12% were living in a consensual union, 15% were previously married (currently divorced, separated, or widowed), and 24% had never been married or lived with a partner. A total of 38% of the respondents had no living children at time of interview, 35% had one living child, and 27% had two or more. The proportion of women who had a child, and the number of children were higher in rural than in urban areas. Education was generally high, with 45% of women having university level education, and 28% had attended other postsecondary education such as colleges and technicums. However, differences in education were notable between urban and rural residents, with only 29% of rural women having attended university compared to 57% of Moscow residents. Three- fourths (75%) of women reported working outside of the home at least 20 hours per week. Figure 3.1 Characteristics of Eligible Women with Completed Interviews by SocioeconomicRegion. Reproductive Health Survey: Russia, 2011 Characteristic Total Socioeconomic Region Moscow Other Large Cities Other Urban Rural Age Group 15–19 12.9 10.2 15.1 12.3 13.8 21.2 16.9 19.3 18.8 14.1 19.8 19.7 18.1 14.1 16.5 18.7 16.7 15.9 16.8 16.6 16.4 24.6 14.9 13.5 16.2 48.2 45.9 49.3 51.0 12.2 13.1 11.9 10.5 15.6 13.9 15.1 14.7 24.0 27.1 23.7 23.8 41.1 42.2 37.9 32.7 35.1 34.5 36.7 32.5 20.0 19.9 22.2 26.4 3.7 3.4 3.2 8.4 5.7 9.8 7.8 12.7 12.1 16.7 17.5 25.2 25.6 23.9 26.8 32.8 56.6 49.6 47.9 29.3 78.4 73.0 76.8 72.5 21.6 27.0 23.2 27.5 100.0 100.0 100.0 100.0 660 1,338 5,327 2,685 20–24 19.0 25–29 18.9 30–34 17.6 35–39 16.5 40–44 Marital Status 15.1 Legally married 49.1 Consensual union 11.8 Previously married 14.9 Never married Number of Living Children 24.2 0 37.6 1 35.3 2 22.7 3 or more Education Level 4.4 Secondary incomplete or less 9.0 Secondary complete 18.7 Technicum 27.7 University Employment 44.6 Working 75.4 Not working 24.6 Total 100.0 No. of Cases 10,010 6 Figure 4.1 Fertility Trends from Official Statistics and Russia Reproductive Health Survey 2011 2.1 1.9 1.3 1.2 1.3 1.5 1.6 1985-1989 1990 1995 2000 2005 2009 RURHS11 Births per Woman Source: ROSSTAT, 2010: 2010 Demographic Yearbook of Russia Replacement Level 0 20 40 60 80 100 120 A n n u al b ir th s pe r 1 0 0 0 w om en 28 97 96 49 23 10 29 88 103 65 27 7 15–19 20–24 25–29 30–34 35–39 40–44 2005-2008 2008-2011 Age Group Figure 4.2 Age-Specific Fertility Rates for the Two 36­ Month Periods Prior to the Survey 0 20 40 60 80 100 120 140 160 A nn ua l b ir th s pe r 10 00 w om en 49 Figure 4.3 Age-Specific Fertility Rates for the Four 60­ Month Periods Prior to the Survey 138 98 27 98 68 46 22 96 87 40 23 29 91 98 60 25 15–19 20–24 25–29 30–34 35–39 40–44 1991-1996 1996-2001 2001-2006 2006-2011 Age Group 7 Chapert 4:Fertility Chapter 4: Fertility One objective of the RURHS11 is to assess current levels and recent trends in fertility and to identify factors that might influence reproductive behaviors. The survey included a series of questions on childbearing, desired family size and fertility preferences. This information represents an important addition to vital statistics routinely compiled at the local and regional levels, because it allows for analysis of fertility differentials by background characteristics and health behaviors. Findings: • Fertility trends found in the RURHS11 were consistent with national statistics, and indicate that the TFR (Total Fertility Rate) rose to 1.6 lifetime births per women in the 2008-11 period (Figure 4.1). This increase in fertility is most pronounced for the age groups 25–29 and 30–34, but there was also a decrease for the age group 20–24 (Figure 4.2). • Figure 4.3 provides a longer term perspective on changes in fertility in the Russian Federation over the 20-year period from 1991 to 2011, which has been broken down into four 5-year periods (1991–1996, 1996–2001, 2001–2006 and 2006–2011). There was a substantial decline in fertility for the three youngest age groups between the periods 1991–1996 and 1996–2001 and this decline continued into the period 2001- 2006 for women 15–24. For women aged 25–39 there was a reversal with age- specific fertility rates increasing over the last fifteen years, but fertility among 20–24 7 Figure 4.4 Age-Specific Fertility Rates for the 36 Months Before the Survey, by Size of Place of Residence 180 160 140 120 100 80 60 40 20 0 A nn ua l b ir th s pe r 10 00 w om en Moscow Other Large Cities Other Urban Rural 15–19 20–24 25–29 30–34 35–39 40–44 Age Group 180 160 140 120 100 80 60 40 20 0 A nn ua l b ir th s pe r 10 00 w om en Figure 4.5 Age-Specific Fertility Rates for the 36 months Before the Survey, by Education Level Secondary incomplete or less Secondary complete Technicum University 15–19 20–24 25–29 30–34 35–39 40–44 Age Group Chapert 4:Fertility year-olds has continued to decline slightly over this period. • Taken together, these figures illustrate a delay in the age pattern of fertility to older ages. As recently as 2001–2006 the peak age group for childbearing was still 20–24, but in the period 2006–2011 the peak age group has shifted to 25–29. • Considering differentials in the TFR, the largest differentials are by size of place of residence (1.3 lifetime births per woman in Moscow vs. 1.8 in rural areas) and by education level (2.1 for women with less than secondary complete versus 1.5 for university educated women). • Figures 4.4 and 4.5 show differentials in the age pattern of fertility by place of residence and education level. The peak age group for rural fertility is 20–24, while fertility is highest at ages 25–29 for the 3 urban areas. Moscow stands out as having fertility comparable to rural areas at ages 25–29 but having the lowest fertility rates of all community size categories at all other ages. Considering education level, university educated women reach their peak fertility at ages 25–29, whereas all three of the less educated categories of women experience their highest childbearing at ages 20–24. There is relatively little variation in fertility levels at ages 30–44. • Figure 4.6 shows trends in the median age at first intercourse, first marriage (or consensual union) and first birth for different birth cohorts of women. The median age is the age by which 50% of the Figure 4.6 Median Ages at First Sexual Intercourse, First Union and First Birth, by Current Age at Time of Survey 15 16 17 18 19 20 21 22 23 24 25 25–29 30–34 35–39 40–44 First Sex First Union First Birth A ge in y ea rs Current Age Group 8 Figure 4.8 Percent Distribution of Women With a Pregnancy Since January 2006 by Planning Status of the Most Recent Pregnancy, by Pregnancy Outcome 61 68 83 4 69 18 22 13 31 15 18 3 3 62 13 3 8 1 4 3 0% 20% 40% 60% 80% 100% Total Current pregnancy Live Birth Induced Abortion Stillbirth or Miscarriage Not Sure Unwanted Mistimed Planned P er ce n t Figure 4.7 Median Ages at First Intercourse, First Union and First Birth, by Education Level 18 23 21 18 22 22 18 22 23 19 23 25 0 5 10 15 20 25 30 Median Age at First Intercourse Median Age at First Union Median Age at First Birth Secondary incomplete or less Secondary complete Technicum University A ge in y ea rs Figure 4.9 Percent of Women Currently in a Formal or Consensual Union Who Want no More Children or Are Undecided, by Number of Living Children 7 21 64 67 5 15 17 16 0 10 20 30 40 50 60 70 80 0 1 2 3 or more Want no more children Undecided P er ce n t Chapert 4:Fertility women have experienced the event in question. The median age at first intercourse has declined about a year from 19.3 (among 40–44 year-olds) to 18.4 (among 25–29 year-olds). The median age at first union has changed little from 22.4 to 22.7. The median age at first birth has risen by more than two years from 22.4 for 40–44 year-olds to 24.9 for 25–29 year-olds, which is consistent with the changing age pattern of fertility shown earlier. The increase in the age at first birth with negligible change in the age at first intercourse is an indication that there have been changes in use of contraception or abortion. • The median age at first birth is considerably older for university educated women (25.1 years) than for women with less than complete secondary education (20.9 years), while the education differential is not as pronounced for ages at first intercourse and first union (Figure 4.7). • Overall, 36.7% of women who had been pregnant since January 2006 reported that their last pregnancy was unplanned, with a similar percent classified as mistimed (18.4%) and unwanted (18.3%) (Figure 4.8). The reported planning status of the pregnancy is related to the outcome of the pregnancy. A full 92.3% of pregnancies terminated by abortion were either mistimed (30.8%) or unwanted (61.5%). A little over two- thirds of current pregnancies and pregnancies resulting in a miscarriage or stillbirth and 82.6 percent of live births were reported as planned. 9 Chapert 4:Fertility • Among women who are currently married or in consensual union 41% want no more children, and an additional 14% are unsure if they want to have more. The intention to have no more children increases rapidly with increases in the number of living children (Figure 4.9). Among women who had had two or more children, approximately two-thirds stated that they wanted no more and an additional 16% were undecided. In contrast, among those with no living children, only 7% said they did not want children and 5% were undecided. 10 3.4 3.0 2.4 1.9 1.4 1.0 1985-1989 1990 1995 2000 2005 2009 Figure 5.1 Abortion Trends from Official Statistics, 1985-2009 Abortions per Woman Source: ROSSTAT, 2010: 2010 Demographic Yearbook of Russia Age Group 0 10 20 30 40 50 60 70 Total Ever Had an Abortion 15-19 20-24 25-29 30-34 35-39 40-44 Figure 5.3 Percentage of Women Age 15-44 Who Ever Had an Abortion, RURHS 2011 35 3 13 30 46 56 61 43 16 50 60 53 37 30 34 11 40 44 43 31 19 TOTAL GAR 15-44 15–19 20–24 25–29 30–34 35–39 40–44 Age Group 2005-2008 2008-2011 Figure 5.2 Three-year General Abortion and Age Specific Abortion Rates Among Women Age 15-44, RURHS 2011 Chapter 5: Induced Abortion Historically, Russian couples have relied heavily on abortion to avoid unintended births. Official abortion statistics documented very high abortion rates during 1970s and 1980s, including 3.4 abortions per woman in the late 1980s. Since then, the total abortion rate (TAR, the number of abortions a woman would have in her lifetime under the current age specific abortion rates) in Russia declined gradually, with a reduction of one abortion per woman at the end of each decade: from 3 abortions per woman in 1990, to 1.9 abortions per woman in 2000 and 1 abortion per woman in 2009, the latest year for which the federal statistics data were available (Figure 5.1). Thus, TAR has declined by 70% compared to its late 1980s level. The RURHS11 asked women about their lifetime pregnancy history, including month and year of each abortion and mini-abortion they might have had. These events were used to calculate 3-year period total (TAR) and age specific abortion rates (ASARs). The RURHS11 abortion findings correlate well with official statistics. The survey found that for the most recent 3-year period prior to the survey, they survey TAR was identical with the official TAR in 2009 of 1.0 abortion per woman. Similarly, the general abortion rate (the number of abortions per 1,000 women age 15–44) of 34 abortions per 1,000 women aged 15–44 documented in the RURHS11, is identical to the official rate for 2010. Chapter 5: Induced Abortion 11 Figure 5.5 Most Important Reason for Abortions Obtained in 2006­ 2011 by Women Aged 15–44 Years Could not Other 24% afford another child 33% She did not want another child Partner opposed to another child 17% Health reasons Birth spacing 11% 10% 5% - Figure 5.6 Gestational Age at Time of Induced Abortions Obtained in 2006-2011 by Women Aged 15–44 Years Under 7 weeks 37% 7 9 weeks 47% 10-12 weeks 14% 13+ weeks 2% Chapter 5: Induced Abortion Findings: • The total abortion rate (TAR) in RURHS11 was examined for two periods of time (2005–2008 and 2008–2011) during which there was an apparent 17% decline (from 1.2 to 1.0 abortion per woman). Almost half of Russian women who obtained abortions in 2008–2011 were 25–29 years of age (44 abortions per 1,000 women) or 30– 34 years (43 abortions per 1,000 women) (Figure 5.2). The relative contribution of 25–34 years of age to the TAR was unchanged between 2005–2008 and 2009– 2011. The third highest age specific abortion rate (ASAR) in both periods, contributing to 20–21% of the TAR, was among women aged 20–24 years. All ASARs declined, but the contribution of ASARs to TAR did not change significantly between the two periods examined. • Overall, 35% of women reported ever having one or more abortions or mini- abortions (Figure 5.3). Among the older cohorts of women, those 35-39 and 40-44 years old, over half of women had had an abortion (56% and 61%, respectively). • The ASARs can also be examined in the context of age-specific fertility rates (ASFRs). After age 35, the ASARs were consistently lower than ASFRs in both periods of time examined, explaining why total fertility rates were significantly higher than the total abortion rates in both periods of time examined (Figure 5.4). Only women aged 35 or older reported more abortions than births, suggesting that these women have already achieved their desired family size at younger ages and Figure 5.4 Three-Year Age Specific Abortion (ASAR) and Fertility Rates (ASFR) in 2005-2008 and 2008-2011, RURHS 2011 0 10 20 30 40 50 60 70 80 90 100 110 15-19 20-24 25-29 30-34 35-39 40-44 Age group ASAR 2005-2008 ASAR 2008-2011 ASFR 2005-2008 ASFR 2008-2011 12 Age Group 62 13 30 19 20 19 5 0 10 20 30 40 50 60 70 Receipt of Methods, Prescriptions, or Referrals Timing of Contraception Counseling In Relation to Abortion Figure 5.7 Family Planning Services Offered Around the Time of Abortion Among Women Who Obtained an Abortion in 2006-2011 64 62 60 52 46 44 44 29 0 20 40 60 80 First Second Third Fourth or higher P er ce n t Abortion Order Information Supplies or referral Figure 5.8 Receipt of Contraceptive Information and Supplies/Referral at the Time of Abortion for Abortions Obtained in 2006-2011, by Abortion Order Chapter 5: Induced Abortion that most of their pregnancies were unplanned and intentionally terminated. • When women were asked about their major reason for choosing abortion, responses included: socioeconomic circumstances that prevent the family from supporting another child (33%), desire to stop childbearing (24%), partner opposition to another child (17%), health reasons (11%), and desire to space the next birth (10%) (Figure 5.5) • Almost half of women (47%) who had an abortion in 2006–2011 reported using contraception at the time of conception, about two-thirds of whom were using modern contraceptive methods, particularly condoms. • Most induced abortions occurring in 2006– 2011 were in-patient procedures (63%) performed in hospitals or maternity wards; 35% were performed in ambulatory clinics, such as women’s consultation clinics (WCCs); and 2% were performed outside medical facilities. Only 6% of abortions required hospitalization of one or more nights after the abortion was completed. A sizable proportion of induced abortions were followed by early (15%) or late complications (7%), regardless of the place where the procedure was performed. • Information about gestational age at the time of induced abortions that occurred between 2006-2011 shows that almost one half of abortions took place between the 7th and 9th weeks of gestation, and that 37% occurred prior to 7 weeks gestation (Figure 5.6). • Receipt of family planning services around the time of having an abortion was reported by 62% of respondents who had an abortion in 2006–2011, with 30% receiving contraceptive counseling only after the procedure, and 19% receiving counseling both before and after the abortion procedure (Figure 5.7). Family planning counseling included distribution of modern contraceptives (20%), prescription to purchase contraceptives (19%), or referral to other services (5%). Women who experienced their first abortion in this time period were the most likely to receive counseling and supplies, suggesting an increase in recent efforts to provide family planning counseling and services around the time of abortion in an effort to prevent repeat abortions (Figure 5.8). 13 Figure 6.2 Information Covered During ANC Visits Received by Women who Gave Birth in the Last Five Years 100 80 88 81 73 73 73 68 56 P er ce nt 60 40 20 0 Information Received During ANC P er ce n t Figure 6.3 Proportion of Births in the Last Five Years Delivered by Caesarean Section, by SES Region and Maternal Age 30 20 21 13 12 14 12 15 10 8 20 10 0 SES Region Maternal Age Chapter 6: Maternal and Infant Health Chapter 6: Maternal and Infant Health Improving maternal and infant health services, increasing birth rates, and reducing maternal and infant mortality by more than half were officially established as top priorities by the Government of Russian Federation in 2007. The goals are set to be achieved by 2025. Under the National Priority Health Care Project, the government has modernized perinatal centers in all regions of the RF, and increased newborn screening, genetic counseling, and comprehensive routine health screening program for orphaned and disadvantaged children. A review by the Presidential Commission for National Priority and Demographic Policy, conducted in May 2011, found that th ese measures have been implemented and have resulted in progress toward the 2025 goals. 90 8 1 4 5 71 20 0 20 40 60 80 100 1st 2nd 3rd <6 7-9 10+ Unknown P er ce nt Number of ANC Visits Trimester of First ANC Visit Figure 6.1 Trimester of First Antenatal Care (ANC) Visit and Number of Visits Received by Women who Gave Birth in the Last Five Years The RURHS11 included numerous questions designed to help understand the current status of health care services for pregnant women, including prenatal, intrapartum, and postnatal services. Questions also gathered information about women’s behaviors around the time of pregnancy, complications experienced during pregnancy and the postpartum periods, birth outcomes, and breastfeeding. Findings: • The RURHS11 found the use prenatal care was almost universal (99%). Nearly 90% of pregnant women initiated prenatal care in the first trimester, and 71% of pregnant women completed ten or more prenatal visits (Figure 6.1). Among women who had prenatal care, 88% received counseling 14 about nutrition during pregnancy; 81% received information about delivery; 73% received information about effects of alcohol, smoking, pregnancy complications and breastfeeding; and 68% were counseled about the importance of postnatal care. Only about 1 in 2 women (56%) received counseling about family planning after birth (Figure 6.2). Figure 6.5 Percent Who Received Family Planning Counseling During Postpartum Care Among Women who Gave Birth in the Last Five Years and Received Postpartum Care, by SES Region 80 60 P er ce n t 40 69 68 70 69 55 SES Region 20 0 Figure 6.4 Postpartum Care and Information Received by Women who Gave Birth in the Last Five Years 100 80 7674 69 65 72 69 80 P er ce n t 60 40 20 0 Received Postpartum Care Information Received During Postpartum Care Chapter 6: Maternal and Infant Health • Hospital delivery was also almost universal, with 99% of the births that occurred in the last five years having taken place in a hospital facility. The average time spent in medical facility prior to delivery was 7.5 hours, and prolonged hospital stay was common, with 73% of women remaining in the hospital for 5 or more days after delivery. Hospital stays of more than 5 days were common regardless of whether there was a pregnancy complication. • Overall, 13% of births were deliveries by caesarian section, ranging from 20% in Moscow to 12% in other large cities and rural areas (Figure 6.3). The proportion of women delivering by caesarian section was directly correlated with age, educational and wealth levels, as expected. Low birth weight babies were more likely than normal birth weight babies to be delivered by caesarian section (23% vs. 13%, respectively), as well as women with pregnancy complication compared with women with no complications (21% vs. 10%, respectively). • Eighty percent of women who delivered in the past 5 years received postpartum care (Figure 6.4). During their postpartum 96 61 32 5 62 31 5 56 36 7 0 20 40 60 80 100 <1 1-2 >2 P er ce n t Total Urban Rural Weeks Between Delivery and First Well-Baby Visit Total Received Well-Baby Visit Figure 6.6 Proportion of Babies that Received Well-Baby Visit by Timing of First Visit and Residence 15 27 14 10 10 7 4 0 5 10 15 20 25 30 P er ce n t Type of Pregnancy Complication Had Any Pregnancy Complication Figure 6.8 Pregnancy Complications Reported by Women who Gave Birth in the Last Five Years P er ce n t Figure 6.9 Postpartum Complications Reported by Women who Gave Birth in the Last Five Years 35 33 30 25 20 15 10 5 0 Had Any Postpartum Complication Type of Postpartum Complication 20 10 7 6 6 12 7 15 11 12 20 13 10 8 21 12 6 11 13 12 12 10 11 12 11 10 14 11 0 5 10 15 20 25 P er ce nt SES Region Smoked During Pregnancy Drank During Pregnancy Maternal Age Education Figure 6.7 Percent Who Smoked Cigarettes or Drank Alcohol During Pregnancy Among Women who Gave Birth in the Last Five Years, by Selected Characteristics 11 Chapter 6: Maternal and Infant Health visits, 76% of women received information about breast care, 74% about breastfeeding, 72% about healthy eating, 69% about childcare and family planning, and 65% information about immunization. Notably, only about one in two women (55%) in Moscow received postpartum family planning counseling, compared to 70% of women in other urban and rural areas (Figure 6.5). • Use of well-baby care was high: 96% of newborns received a well-baby check-up, and majority of them (61%) received the examination during the first week following delivery (Figure 6.6). An additional 32% of infants were brought for their initial checkup one to two weeks after delivery, and 5% made their first visit more than two weeks following delivery. • No amount of alcohol or tobacco use is considered safe during pregnancy. One in five women (21%) smoked before pregnancy, and more than half of them (12%) continued to smoke during pregnancy (Figure 6.7). Overall 11% of mothers used alcohol during pregnancy, ranging from a low of 10% in rural areas to a high of 13% in Moscow. • Nearly 27% of mothers experienced some pregnancy complication; most often cited were risk of preterm delivery, edema, anemia, high blood pressure, and bleeding during the first six months (Figure 6.8). As expected, complications requiring medical attention were more prevalent in older mothers. Postpartum complications were reported by 33% of respondents, and the most common conditions were painful uterus and breast infections (Figure 6.9). 16 Figure 6.11 Infant and Child Mortality Rates (per 1,000 Live Births) Among Children Born in the Last Five Years Mortality Rates Rate Confidence Interval Infant Mortality 10.7 (6.6-14.8) Neonatal 9.2 (5.3-13.1) Postneonatal 1.4 (0.0-2.9) Early Child Mortality (1-4) 1.9 (0.0-4.0) Under 5 Mortality (0-4) 12.6 (8.0-17.2) Number of Cases 2,932 - Figure 6.10 Timing of Breastfeeding Initiation After Delivery Among Children Born in the Last Five Years < 1 Hour 25% 1 23 Hours 53% 24-47 Hours 8% 48+ Hours 9% Unknown 4% Total Ever Breastfed: 92% Chapter 6: Maternal and Infant Health • According to the survey data, the low birth weight rate (percentage of live births <2500 grams) was nearly 4%. The low birth rate was higher among Moscow residents (7%), women younger than 20 years old (7%), with lowest education level (5%), women who did not received prenatal care (10%), who experience pregnancy complications (6%), and who underwent cesarean section before labor started (10%). • The percentage of live births delivered prematurely (before 37 weeks of gestation) was 4%. Higher prematurity rates were associated with Moscow residence (7%), maternal age younger than 20 (7%), third or higher birth orders (8%), pregnancy complications (7%), cesarean section before labor started (10%), and the rate was highest among women who didn’t receive any prenatal care (19%). • More than 9 out of every 10 infants born in the last five years (92%) were breastfed (Figure 6.10). However, only one in four infants was breastfed during the first hour after delivery. About 78% of all babies, 56% of low birth weight babies and nearly half (49%) of cesarean section babies were breastfed in the first 24 hours. • The survey data show that the infant mortality rate during 2006–2011 was 10.7 deaths per 1,000 live births, including a neonatal mortality rate of 9.2 and a postneonatal mortality rate of 1.4. The under-5 mortality rate was 12.6 per 1000 live births (Figure 6.11). The greatest contributor to under-5 mortality was infant mortality, with majority of infant deaths occurring in the neonatal period. The risk of infant mortality was about three times higher among third or higher birth order compared to first birth (26.4 and 7.7 per 1000, respectively), and four times higher among births occurring within a birth interval of under 24 months compared to births occurring after an interval of 24 months or greater (31.8 vs. 7.7 per 1000, respectively). 17 Figure 7.1 Awareness and Knowledge of How to Use Modern Contraceptive Methods Among Women Aged 15-44 Years 99 97 93 67 58 52 25 94 83 74 42 50 30 18 0 20 40 60 80 100 P er ce nt Awareness Knowledge of Proper Use Figure 7.3 Percentage of Women Aged 15-44 Years Who Said They Know How Selected Methods Are Used, by Age Group 89 71 52 22 37 16 10 58 38 97 88 81 46 56 32 20 86 65 98 89 89 58 55 42 26 89 75 0 20 40 60 80 100 P er ce n t Contraceptive Method 15-24 25-34 35-44 Figure 7.2 Percentage of Women Aged 15-44 Years Who Had Heard About Contraceptive Methods, by Age Group 98 94 81 42 46 31 14 64 52 100 99 98 75 65 57 27 91 79 100 99 99 84 64 67 33 94 87 0 20 40 60 80 100 P er ce n t Contraceptive Method 15-24 25-34 35-44 Chapter 7: Contraceptive Knowledge Chapter 7: Contraceptive Knowledge The Russia 2011 Reproductive Health Survey collected information on whether women had awareness of specific contraceptive methods and whether they knew how specific contraceptive methods were used. Women were also asked where methods can be obtained, how effective they believe the methods are, and whether they knew how to use the methods correctly. This information is valuable for information, education, and communication efforts, and for monitoring improvements in knowledge over time. Findings: • Russian women are very well informed about contraceptive methods. Virtually all (99.5%) women of all ages have heard of at least one modern method (Figure 7.1). The vast majority of women recognized the three best known methods: condoms (99%), oral contraceptives, (Pill) (97%), and the IUD (93%). Well over half of women had also heard of female contraceptive sterilization (tubal ligation) (67%), emergency contraception (58%) and male contraceptive sterilization (vasectomy) (52%). Fewer women had heard of the injectable hormonal contraceptive or of hormonal implants (25% combined). • Although the youngest women (15-24) were nearly as knowledgeable as the older groups about condoms and oral contraceptives, there was a much bigger difference between younger and older groups with all the other methods. Because female sterilization is restricted by law to women over age 35 or with two or 18 92 82 53 50 34 19 Figure 7.4 Knowledge of a Source for Specific Modern Contraceptive Methods Among Woman Aged 15-44 Years 96 90 80 100 70 60 P er ce n t 50 40 30 20 10 0 100 80 60 P er ce nt 40 Figure 7.5 Knowledge of a Source for Specific Contraceptive Method, by Age, Among Woman Aged 15-44 Years 97 96 99 99 98 20 0 Contraceptive Method 95 93 86 95 62 88 94 40 60 57 15-24 2 28 5-34 54 66 35-44 Chapter 7: Contraceptive Knowledge more children, it is not surprising that this method was familiar to only 42% of women aged 15 to 24, whereas the rate was twice as high (84%) for women aged 35-44 (Figure 7.2). • Knowledge of how contraceptive methods are used was somewhat lower than awareness of the methods themselves, • Most women of reproductive age could name at least one source for at least two methods of contraception. Almost all or female sterilization (50%), and knowledge of where to obtain injectables was scarce (only 19%). • Knowledge of a source for all contraceptive methods increased by age, with the exception of emergency contraception, for which the middle age cohort (ages 25-34) was more likely to know a source (60%) than were the older and younger age groups (Figure 7.5). Figure 7.6 Most Important Source of Information About Contraception Among Women Age 15-44 Years Friends, 20% Doctor , 17% Partner/ Husband, 14% Print media, 8% Parent, 7% Nurse, 6% TV/Radio, 6% Boyfriend, 4% Books, 4% Internet, 4% Other, 11% particularly for the youngest age group. Knowledge of how methods are used increased with age, particularly for methods not used or little used by younger women, such as female sterilization (increasing from 22% of the youngest cohort to 58% of the oldest) and the IUD (52% and 89%, respectively) (Figure 7.3). respondents (96%) knew where to get condoms, and 92% knew where to get oral contraceptives, with somewhat fewer knowing where to obtain an IUD (82%) (Figure 7.4). However, only half knew a source for emergency contraception (53%) 19 Chapter 7: Contraceptive Knowledge • The Russia 2011 RHS found that women aged 15-44 years obtained information about contraceptive methods almost equally from a friend (20%) or from a doctor (17%), and that a partner or husband was also an important source of information (14%), but a boyfriend considerably less so (4%) (Figure 7.6). Younger women were more likely to report that a friend was the most important source of information (23%), whereas older women more often cited a doctor or partner/husband (Figure 7.7). • Knowledge about the effectiveness of specific contraceptive methods indicates the quality of contraceptive counseling and of information and education programs. In the Russia 2011 RHS, respondents correctly identified tubal ligation as the most effective method (despite the fact that 31% of respondents had never heard of the method; those who were familiar with it knew how effective it is) (Figure 7.8). However, women tended to underestimate the effectiveness of the IUD; although the method is 99% effective, 58% rated it as effective and only 24% as very effective. They correctly identified oral contraceptives to be effective (68%) rather than very effective (18%). While overall the traditional methods were correctly viewed as not being very effective, a significant proportion (41%) thought the calendar method was effective, and over half (55%) said withdrawal was effective. 20 23 19 18 17 11 18 20 14 8 15 16 8 7 8 9 0 10 20 30 All Women 15-24 25-34 35-44 P er ce nt Friends Doctor Partner/Husband Print media Age Group Figure 7.7 Main Source of Information about Contraception by Age Group Among Women Aged 15-44 Years Who Have Heard of Specific Methods 46 24 18 17 1 3 14 58 68 74 41 55 0 2 2 4 24 20 0 20 40 60 80 P er ce nt Very Effective Effective Not Effective Figure 7.8 Opinions on the Contraceptive Effectiveness of Specific Methods Among Women Aged 15-44 Years 20 10 2 12 21 12 1 13 13 25 11 2 14 11 28 12 1 10 10 37 12 1 13 14 25 0 20 40 Withdrawal Female sterilization Pill IUD Condoms Total Moscow Other Large Cities Other Urban Rural Figure 8.3 Percent of Currently Married Women Aged 15–44 Years Who Use Specific Contraceptive Methods, by SES Region Figure 8.1 Contraceptive Use Status among All Women Aged 15–44 Years Never Used a Method 17% Previous User 31% Current User 52% 65 53 68 54 70 57 76 61 68 55 0 20 40 60 80 Any method Any modern method Total Moscow Other Large Cities Other Urban Rural Figure 8.2 Percent of Currently Married Women Aged 15–44 Years Who Use a Contraceptive Method, by Residence Percent Currently Using Chapter 8: Current and Past Contraceptive Use Chapter 8: Current and Past Contraceptive Use Modern methods of contraception are not only widely known in Russia, but they are also widely used. Questions about current use of contraception among currently married women, as well as reasons for non-use comprise an important focus and contribution of the RURHS11. Findings: • Russia is a high contraceptive use country, as demonstrated by the large percentage of women of reproductive age who are current users (52%) or previous users (31%) (Figure 8.1). In general, 83% of all women aged 15–44 had ever used a contraceptive method at some time in their lives, and almost all of them (81%) had used a modern method (including condoms, oral contraceptives, IUD, female sterilization, injectables, and spermicides). Additionally, 59% of respondents had used a traditional method (periodic abstinence or withdrawal) at some time in their lives. Ever-use of contraception is low among the youngest age group, likely because most have not yet become sexually active. By their late 20s, over 90% of women have used a contraceptive method, almost all of them having used a modern method. • Among currently married women, contraceptive prevalence of modern methods was 55% and rose to 68% when traditional methods were taken into account (Figure 8.2). Residential differences in contraceptive prevalence among currently married women revealed somewhat higher prevalence in urban 21 Figure 8.6 Sources of Supply for Modern Methods Among Women Age 15-44 Who Currently Use a Modern Method 80 72 60 40 20 14 10 3 3 0 Pharmacy Women's Partner/Husband Hospital Store/Kiosk Other Consultation Clinic Source of Contraceptive Method 4 Figure 8.5 Percent of Currently Married Women Aged 15–44 Years Who Use Specific Contraceptive Methods, by Age Group Condoms IUD Pill Female sterilization Withdrawal 11 3 9 24 11 3 12 19 22 11 1 15 16 23 12 13 9 28 12 14 4 30 7 9 2 30 0 20 40 15-19 20-24 25-29 30-34 35-39 40-44 80 70 60 50 40 30 20 10 0 Figure 8.4 Current Total Contraceptive Use and Modern Contraceptive Use Among Currently Married Women Aged 15–44, by Age Group 68 55 50 62 42 50 Total Modern 64 51 70 57 73 59 72 57 Age Group Chapter 8: Current and Past Contraceptive Use areas, particularly in Moscow, compared to rural areas. • The most popular modern method was the condom, which was used by a quarter (25%) of married women, even though it is not one of the most effective methods (Figure 8.3). Use of the IUD by married contraceptive users (14%) and use of oral contraceptives (13%) were relatively low. Differences in use by residence among currently married women were not large, except in the case of condoms, where use ranged from 37% in Moscow to a low of 21% among rural residents. The IUD had the reverse pattern, being least popular in Moscow and most popular in rural areas. • Both total and modern contraceptive use increased gradually with age (Figure 8.4). The method mix varied according to age group: among younger women condoms and oral contraceptives were most common, whereas use of the IUD increased with age (Figure 8.5). Contraceptive use also increased with education, although a majority (61%) of even the least educated use contraception. • The pharmacy was the most important source of contraceptive methods, with almost three-quarters (72%) of all current users seeking supplies there (Figure 8.6). Oral contraceptives and spermicides were almost exclusively (93%) obtained from pharmacies, as were most condoms and other modern methods (79%) and even a large proportion of IUDs (43%). Among the medical facilities, only the women’s consultation clinics provided a substantial proportion (14%) of contraceptives; they 22 Figure 8.8 Reasons for Non-Use of Contraception among Currently Married Women Aged 15–44 Years Does not think about using a Uses Other method douching 5% Does not know Partner objects 4% 2% 2% Not sexually active 9% 26% Desires pregnancy 26% Subfecund, menopausal, or operated 23%Currently pregnant 7% Figure 8.9 Contraceptive Discontinuation Rates After One Year Among All Segments of Use Since 2005, by Primary Reason for Discontinuing, and Method 5960 40 20 0 53 14 10 9 8 7 22 7 8 91010 44 7 24 3 1 10 1 1 5 0 10 Total Condoms Pill IUD Sporadic Stopped to rest Switched to Desired to Partner's Total % Who sexual activity body/Physician other method become objections or Discontinued Advise pregnant absence Reason for Discontinuing Chapter 8: Current and Past Contraceptive Use were more popular with rural women, older women, and those in the lowest economic quintile. These clinics were also the leading source for IUDs (47% of women get their IUDs in women’s consultation clinics). Due largely to the low use of tubal ligations, hospitals as a source were reported by only 4% of women. • Overall, Russian women were reasonably satisfied with their current contraceptive methods; however, 18% of women desired to use a different method (Figure 8.7). Preferred methods over the current method included IUD for almost half of dissatisfied users (45%) and over a quarter who would prefer to use the pill over their current method (29%). Desire for female sterilization and injectables in place of the current method were under 5%. • A quarter of currently married women were not using contraception at the time of the survey, with the most commonly stated reasons being that they were currently pregnant or postpartum (26%) or wanting to become pregnant (26%) (Figure 8.8). Twenty-three percent said they were not at risk of pregnancy because they were subfecund, menopausal, or had had an operation. Nine percent of currently married non-users were not sexually active, and 7% said their partner objected to contraceptive use. • Among respondents who had discontinued using a contraceptive method at some point in the last five years (contraceptive discontinuation, defined as use of a method for less than 1 year), the Figure 8.7 Percent of Current Contraceptive Users Who Would Prefer A Different Method, and Method Preferred IUD 45% Pill 29% Female Sterilization 5% Injectibles 4% Condoms 4% Other 8% Does not know 5% Users Who Would Prefer A Different Method: 18% 23 Chapter 8: Current and Past Contraceptive Use leading reasons for discontinuation were that sexual activity was sporadic (14% of discontinuations), they stopped to give their bodies a “rest” (10%), they switched to a different method (9%), and they wished to become pregnant (8%) (Figure 8.9). Few women reported discontinuing because the method was too expensive or difficult to obtain or because they thought the method was not effective. Reasons for discontinuation varied by method. For the IUD, the leading reasons were physician’s advice and the perceived need to stop use in order to “rest the body” (10%), side effects (6%), and health concerns associated with the IUD (3%); for the condom, that sexual activity was sporadic (22%) and they switched to another method (10%); and for oral contraceptives, physician’s advice (24%), in order to get pregnant (10%), and side effects (9%). 24 8 8 11 4 6 8 10 17 21 16 7 11 18 21 0 5 10 15 20 25 Total Unmet Need Unmet Need for Modern Methods Marital Status Age group Figure 9.1 Current Unmet Need for Any Contraception and Modern Contraception Among Women Aged 15–44, by Marital Status and Age Group Figure 9.3 Number of Current Users of All Contraceptive Methods and Potential Additional Future Users of Modern Methods Among Women Aged 15–44 Years 10.5 million 10.5 million 2.6 million 2.1 million 0 2 4 6 8 10 12 14 16 RURHS 2011 Future If current non-user adopt a modern method If current users of traditional methods adopt a modern method Current users of modern methods 17 16 14 17 18 9 21 22 25 0 5 10 15 20 25 30 Residence No. Living Children Figure 9.2 Current Unmet Need for Modern Contraception Among Women Aged 15–44, by Residence and Number of Living Children Chapter 9: Need for Contraceptive Services Chapter 9: Need for Contraceptive Services The estimated level of unmet need for contraception is information that can guide programmatic efforts to ensure that a population’s family planning needs are being satisfied, thereby reducing the number of unintended pregnancies. Women with unmet need for contraception are those who are currently sexually active and think they are able to get pregnant, who have said that they do not want to become pregnant, but who are not using a contraceptive method to avoid a pregnancy. Unmet need for any type of contraception refers to women at risk of pregnancy who are not using any method to prevent pregnancy; unmet need for modern contraception also includes those women at risk of pregnancy who are using traditional methods, which have considerably higher failure rates than modern contraceptive methods. Findings: • Overall, 8% of women in the survey had unmet need for contraception, and when users of traditional methods were included, 17% had unmet need for a modern method of contraception (Figure 9.1). One in every five married women were identified as having unmet need for a modern method, as were 16% of previously married women and 7% of never married women. Among women aged 35-44, unmet need for a modern method was 21%, compared to 18% unmet need found among women aged 25-34 and 11% among those aged 15-24. 25 Chapter 9: Need for Contraceptive Services Levels of unmet need for modern contraceptive methods were higher among women residing in rural and “other urban” areas compared to those living in large cities other than Moscow (Figure 9.2). Unmet need increased with number of living children. • Based on the RURHS 2011 current contraceptive prevalence rate, in 2011 approximately 10.5 million women in Russia were using modern contraceptive methods (Figure 9.3). If women with an unmet need for any contraception were to adopt a modern method, then contraceptives and services would be needed for an additional 2 million women. Additionally, if women who are currently using less effective traditional methods were to start using more effective modern methods, then modern contraceptives and services would be needed for a further 2.6 million women. 26 77 85 38 45 9 5 4 2 7 1 7 3 10 Figure 10.2 Source of Advice on Most Recent Contraceptive Method by 100 80 60 40 20 0 Method Used Among Women Aged 15–44 Ob/Gyn Partner Nobody Pharmacist Friend 96 Pill IUD Condom Female Sterilization P er ce n t 100 8483 8381 7780 7373 69 67 61 60 40 20 0 Total Pill Counseled Figure 10.3 Type of Counseling Received by Women Aged 15–44 By Method On Side Effects Information on other methods Comprehensive 86 87 IUD Condoms Female Sterilization What To Do if Side Effects On Method's Effectiveness 88 81 73 73 66 63 59 65 60 62 42 41 31 P er ce nt Chapter 10: Contraceptive Counseling Chapter 10: Contraceptive Counseling The RURHS11 included a series of questions about interactions between family planning providers and their clients. The survey asked about the extent to which health professionals provided basic family planning information and services to women who had used a modern contraceptive method or had an abortion or a birth during the five years before the interview. Findings: • Women who had used at least one modern contraceptive method in the previous five years were asked who had advised them to use their most recent method and, if the advice came from a health care provider (e.g., a physician, nurse, or midwife), what topics were covered during family planning counseling. Over one-third of women (39%) were advised by an Ob/Gyn to use their current or most recent method. However, taken together, a greater proportion of women had either received no advice (29%) or had been advised by their partner/husband (22%) or a friend (5%) (Figure 10.1). Women in rural areas were more likely (44%) to have received advice from a doctor than were urban women (38%). Urban women were more likely (30%) not to have sought advice from anyone than were rural women (24%). • The source of advice varied widely by the most recent modern contraceptive method used. Almost all IUD users and women with tubal ligation had chosen their method based on the advice of a health 39 29 22 5 38 30 22 6 44 24 23 4 0 10 20 30 40 50 Ob/Gyn Nobody Partner/Husband Friend P er ce nt Total Urban Rural Figure 10.1 Source of Advice on Most Recent Contraceptive Method by Place of Residence Among Women Aged 15–44 27 Chapter 10: Contraceptive Counseling care provider (97% and 86%, respectively), but only 7% of condom users were advised by a physician, nurse, or midwife (Figure 10.2). Most women who had used condoms did not receive advice from any source (45%) or their partners suggested it (38%). Among women who used oral contraceptives, 77% were advised by a health care provider to do so, but 9% made the decision on their own; an additional 5% were advised by a pharmacist, and 4% by a friend. • During provider-client interactions, 73% of women received general information about other contraceptive methods as well; 69% were counseled about the effectiveness of the chosen method compared with other methods; 83% reported that the provider had explained the possible side effects of the method chosen; and 81% reported they were told what to do if they experienced side effects (Figure 10.3). Overall, 61% of women received comprehensive counseling (i.e., all these topics). The content of contraceptive counseling varied by the method chosen. Condom users were more likely to be counseled about other methods and about method effectiveness; IUD and pill users were more likely to be counseled about possible side effects and what to do if they occurred. Female sterilization users were least likely to receive counseling, especially information about other methods (42%) or contraceptive effectiveness (41%). 28 Figure 11.2 Opinions Regarding the Advantages and Disadvantages of Using Oral Contraceptives (OCs) Among Women Aged 15-44 Who Ever Heard of OCs 100 80 60 40 20 0 Easy to Easy to Regular Reduced May Cause Difficult to Very Bad for Get Use Periods Bleeding Weight Remember Expensive Blood Gain to Take Circulation 93 87 66 5552 41 32 Advantages Disadvantages 16 Figure 11.3 Opinions Regarding the Advantages and Disadvantages of the IUD Among Women Aged 15-44 Who Ever Heard of the IUD 80 60 40 20 0 67 56 54 44 Easy to Use Relatively Increases the Risk May Increase Blood Inexpensive of Pelvic Loss Inflamatory Disease Advantages Disadvantages Chapter 11: Opinions About Contraception Chapter 11: Opinions About Contraception Although overall awareness of contraceptives in Russia is very high (over 90% of women know at least three methods), some modern methods are not well known, knowledge about the effectiveness of some modern methods is lower, and traditional methods are thought to be more effective than they actually are. The RURHS11 asked women their opinions about different contraceptive methods in order to know in more detail what they think about contraceptives, since their opinions and fears about contraceptives ultimately influence their contraceptive practices. Findings: • All survey respondents were shown a list of 11 contraceptive methods and were asked to identify the most effective method. Although female sterilization has the highest use-effectiveness, only 17% of women named it as the most effective method, and only 5% named male sterilization (the second most effective method) (Figure 11.1). The greatest proportion of respondents (23%) ranked the IUD highest (actually, it’s the third most effective method). Condoms (22%) were ranked ahead of oral contraceptives (20%), although orals are more effective. In the “other modern” category, which included Norplant, emergency contraception, and injectable contraceptives (all very highly effective methods), only 2% of the respondents identified this category of methods as being most effective. 17 5 23 20 22 2 1 2 1 7 0 5 10 15 20 25 Figure 11.1 Opinions Regarding Which Contraceptive Method is Most Effective Among Women Aged 15–44 Years Most effective P er ce n t w h o th ou gh t m os t ef fe ct iv e m et h od Least effective 29 Figure 11.5 Opinions Regarding the Best Source of Information About Contraceptive Methods 70 60 50 40 30 20 10 0 64 8 6 5 3 3 3 3 2 3 Figure 11.4 Opinions Regarding the Level of Health Risk Associated with Using Selected Contraceptive Methods Among Ever-Married Women Aged 15–44 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pill IUD Condom Fem. Injectibles Abortion Sterilization 18 54 18 10 15 47 22 16 85 9 5 2 5 12 46 38 14 19 65 2 6 86 7 1 Low Risk Medium Risk High Risk Does Not Know Chapter 11: Opinions About Contraception • Women who had heard of oral contraceptives and the IUD were asked about the advantages and disadvantages of each of these methods. The vast majority of respondents felt the pill was easy to get (93%) and easy to use (87%) (Figure 11.2). They were less likely to mention that the pill makes menstrual periods more regular (52%) and reduces menstrual bleeding (32%). Two-thirds (66%) of respondents were aware that the pill may cause weight gain, while 55% said that remembering to take the pill every day is difficult. A fairly large proportion (41%) felt that the pill is too expensive, but only 16% thought that the use of the pill is “bad for blood circulation.” The youngest women (15-19 years old) were less likely to see disadvantages to oral contraceptives than were older women. • Among women who had heard of the IUD, two-thirds agreed with the statement that the IUD is “easy to use,” and 58% agreed that the IUD is “relatively inexpensive” (Figure 11.3). Over half (54%) knew of the disadvantages that IUD use increases the risk of pelvic inflammatory disease, while 44% knew that IUD use can increase blood loss during menses. Married women and older women were substantially better informed on the IUD’s advantages and disadvantages than were younger and never married women. • Women were asked to evaluate the degree of risk to a woman’s health associated with the use of five modern contraceptive methods and abortion on request. Women perceived the risk to be lowest for condoms (85% low risk) (Figure 11.4). More than two thirds of respondents believe that there is a medium or high risk associated with oral contraceptive (72%) and IUD (69%) use. Nearly half the respondents (46%) felt that there was a high risk associated with female sterilization. A large proportion of women did not know if injectables (65%) or tubal ligation (38%) posed a risk to a women’s health; this may be due in part with women’s lack of familiarity with these methods. 30 Chapter 11: Opinions About Contraception • Among the women surveyed, abortion was nearly universally (86%) perceived to pose a “high risk” to a woman’s health, with only 1% perceiving it as low risk (Figure 11.4). Women who had never had an abortion were more likely to perceive it as high risk (90%) than were those who ever had one (71%). An increased awareness that abortion poses risks to a women’s health could lead to greater use of modern contraceptives. However, the results suggest that more efforts are needed to increase awareness of the risks of abortion among younger and less educated women. • Among women who indicated an interest in receiving more information about contraception, 64% considered a gynecologist to be the best source, followed by 8% who thought newspapers and magazines would be the best source and 7% who chose TV (Figure 11.5). Thus, mass media does not seem to be considered a primary source of information; newspapers, TV, and books together are considered the best source by only 17%. This differed by age groups, with the older cohorts favoring a gynecologist as the preferred source of information, and the young a dults turning more to their mothers, the Internet, contraceptive users, and friends. 31 Figure 12.3 Opinions About What a Woman Should Do if She Has an Unwanted Pregnancy Among Women Aged 15–44 Years, by Age 100 80 P er ce nt 60 40 20 0 13 Have abortion 2 19 5 Give birth/keep baby 14 3 11 Give birth/give baby up 2 11 Don't Know 2 31 39 35 31 25 54 49 56 63 37 Total 15-19 20-24 25-34 35-44 Age Figure 12.2 Knowledge of When a Woman is Most Likely to Become Pregnant Among Women Aged 15–44 Years, by Age 100 80 P er ce n t 60 40 20 0 Just before period During Just After Halfway Between Don't Know Anytime 18 20 6 13 5 10 7 46 8 61 10 55 66 72 29 9 2 4 3 7 5 11 1 5 4 2 9 8 4 1 Total 15-19 20-24 25-34 35-44 Age Chapter 12: Reproductive Health Knowledge and Opinions Chapter 12: Reproductive Health Knowledge and Opinions The RURHS 2011 explored opinions among Russian women about ideal family size, knowledge of the menstrual cycle, induced abortion, and gender roles. Findings: • Over half of women (55%) stated that 2 children is an ideal family size, and an additional 20% favored having three children (Figure 12.1), well above the actual total fertility rate of 1.6 children per woman. About 8% of survey respondents stated that a young couple should have as 8 7 11 8 6 55 46 55 57 54 20 14 16 20 24 1 1 1 1 25 8 5 5 4 8 18 8 6 7 3 5 4 3 3 0 20 40 60 80 100 Total Moscow Other Large Cities Other Urban Rural 0-1 2 3 4+ As many as God gives As many as possible Unsure SES Region Figure 12.1 Opinions on Ideal Number of Children for a Russian Family Among Women Aged 15–44 Years, by SES Region P er ce n t many children as possible, while 5% stated that a young family should have as many children as God gives. Fewer than one- tenth of the respondents (8%) thought that not having any children or only one child was ideal. Residents of Moscow were more likely to favor having as many children as possible (18%) compared to residents of other parts of the country (6%–8%). • In Russia, approximately 10% of married women use a traditional method of contraception, either withdrawal (8%), the rhythm method (1.4%), or a combination of both, for which knowledge of the time during the menstrual cycle when a woman is most likely to get pregnant is important. In the RURHS11, 61% of respondents correctly stated that the highest risk of becoming pregnant is halfway between the two menstrual periods (Figure 12.2). Level of knowledge increased with age. Overall, one-third (32%) of respondents had incorrect beliefs or did not know when the risk of pregnancy is higher. 32 Figure 12.4 Agreement with Statements on Gender and Reproductive Norms Among Women Aged 15–44 Years 91 87 84 42 29 23 20 20 Woman Woman Woman All people Women Child care Women Good wife can ask can refuse can get should must have is woman's must be obeys husband to sex if pregnant at marry children job virgins at husband use husband first sex God gives marriage condom if has STI he has STI Chapter 12: Reproductive Health Knowledge and Opinions • Exploring opinions about abortion, women were asked, “If a woman had an unwanted pregnancy, what should she do?” Fifty- four percent of respondents said that the woman should have an abortion, while 31% said that the woman should give birth and keep the baby (Figure 12.3). Those who were less likely to mention abortion as an option included younger women, never-married women, women in Moscow, and women with no living children. Rural women, previously married woman, and older women were more likely to favor the abortion option. • The survey asked women a series of questions about expectations about women and their roles. Overall, 91% of respondents agreed that a woman should be able to ask her husband to use a condom if he has a sexually transmitted infection (Figure 12.4). Large majorities also agreed that a woman can refuse sex with her husband if he has an STI (87%). Widespread agreement was also found with the statement that a woman can get pregnant the first time she has sex (84%). Less than half of women (42%) agreed that all people should marry. Less than a third (29%) of respondents agreed that a “women should have as many children as God gives them,” and a quarter (23%) of respondents agreed that “child care is a women’s job”. Only one in five women agreed that women must be virgins at marriage, or that a good wife must obey her husband. 33 62 64 37 16 0 20 40 60 80 Sought Any Medical Care Preventive Care Acute Care Chronic Condition P er ce n t Type of Care Sought Figure 13.1 Medical Care Sought in the Past 12 Months, by Type of Care 30 25 20 21 20 15 13 11 10 10 8 10 6 5 0 Total Unable Does Doctor's Could Wait Does Work Delayed to get not office not too not related Seeking appointment have not afford long like reasons Health Care time open service Figure 13.2 Delayed Seeking Health Care in past 12 Months, and Most Commonly Cited Reasons for Delay Among Women Aged 15–44 Chapter 13: Women’s Health Chapter 13: Women’s Health Despite recent advancements in prevention, diagnosis, and treatment, gynecologic cancers remain a leading cause of death in women of reproductive age. Some women face barriers to accessing preventive health services where they can receive screening and early treatment. In addition, tobacco and alcohol use pose serious health risks for Russian women. The recent World Health Organization Global Tobacco Survey conducted in Russia in 2009 revealed that more than one in three adults (39%; 43.9 million) in the Russian Federation currently smoked tobacco. In addition to lung cancer and cardiovascular diseases, smoking poses specific risks to women, including increased risk of cervical cancer and, among older women, increased risk for heart disease associated with taking the contraceptive pill. To examine these health issues, the RURHS11 included questions regarding recent preventive health practices (including routine gynecologic exams, breast self-exam, and cervical cancer screening), other health behaviors (i.e., cigarette smoking and alcohol use), and self-reported health conditions. Findings: • Sixty-two percent of Russian women reported having accessed some type of medical care service in the past 12 months. Over half of women reported that the medical care they sought was for a preventive service (64%), 37% for an acute health condition, and 16% for a chronic health condition (Figure 13.1). University- educated women reported having sought primary care (67%) to a greater extent than women who had not completed 81 86 21 45 0 20 40 60 80 100 35–39 40–44 P er ce nt Age Group Ever Had CBE Ever Had Mammogram Figure 13.3 Percent of Women aged 35-44 Who Ever had a Clinical Breast Exam (CBE) or Mammogram, by Age 34 Figure 13.4 Most Commonly Cited Reasons for Never Having Had a Mammogram Among Women Aged 35–44 Years Doctor Never Recommended 71% No Need/ Too Young 16% Never Heard of Mammogram 4% Other 5% Negligence 5% 18 24 30 29 13 17 20 18 4 7 8 7 64 52 42 47 0 10 20 30 40 50 60 70 <Secondary Secondary Complete Technicum University P er ce n t Education Past 12 Months 1-3 Years 3+ Years Never Had Figure 13.5 Timing of Most Recent Cervical Cancer Screening by Education Among Women Aged 15–44 Years Figure 13.6 Current Smoking Prevalence Rates Among Women Aged 15–44 Years, by Age Group and Education 40 30 20 10 0 24 20 26 26 25 24 18 20 32 25 20 Education Age Group P er ce nt Chapter 13: Women’s Health secondary school (55%). The latter reported seeking care for an acute condition with greater frequency (46%) compared to university-educated women (35%). • One in five respondents (20%) reported that they had delayed seeking health care in the past 12 months. Inability to get an appointment (21%), not having the time to go (13%), and the medical office not being open (11%) were the three most commonly-cited reasons for delaying needed care (Figure 13.2). • Approximately 8 out of every 10 Russian women 35-44 years of age reported ever having had a clinical breast exam. In contrast, mammography was much less common among women in the older age ranges, with less than half of women aged 40-44 (45%) reporting that they ever had a mammogram (Figure 13.3). When asked why they had never had a mammogram, the most common response among women 35-44 years of age was that a doctor had never recommended it (71%) (Figure 13.4). • Although over 90% of women reported having had a routine gynecological examination with the past three years, the prevalence of cervical cancer screening was low among Russian women. Notably, 47% of Russian women had never had a Papanicolaou test to screen for cervical cancer, including approximately one in three women aged 35 and older. Prevalence of ever having had an exam and of having had a Papanicolau test was greater among more highly educated women compared to those with less education (Figure 13.5). 35 Chapter 13: Women’s Health • Almost one in four Russian women (24%) reported that they currently smoke cigarettes, including 18% who smoke daily and 6% who smoke occasionally (Figure 13.6). Respondents residing in Moscow and particularly residents of other large cities were significantly more likely than rural respondents to be current smokers. Current smoking peaked among 20–29 year olds, and was particularly high among women who had completed secondary school. • All women were asked how often they drank alcohol, and how many drinks they had on a single occasion during the last three months. One drink was defined as one glass of wine (150ml), one bottle of beer (350ml), or one shot of hard liquor (vodka, whiskey or similar, 50ml). On average, 51% of women reported that they are current drinkers (had a drink in the past 3 months), and 10% reported that they are current frequent drinkers (consumed alcohol daily or almost daily in the past 3 months) (Table 13.7); 14% of women reported at least one recent episode of binge drinking (4 or more drinks within several hours). 51 42 55 56 29 50 56 54 10 9 11 10 7 11 10 10 14 10 15 16 8 16 15 13 0 20 40 60 80 P er ce n t Current Drinker Current Frequent Drinker Binger Age Education Figure 13.7 Drinking Prevalence Rates by Age Group and Education Among Women Aged 15–44 Years 36 Figure 14.2 Young Women 15-24 who had Discussed Family Life Education Topics with a Parent Before Reaching Age 18 100 P 80 e r 60 c e n 40 t 20 0 92 88 57 55 53 45 44 Any Topic Menstrual Cycle No Premarital Sex Pregnancy HIV/AIDS Contraception Other STIs Chapter 14: Family Life Education Chapter 14: Family Life Education High rates and acceptance of premarital intercourse, risk of HIV/AIDS and other sexually transmitted infections, and related sexual and reproductive health behaviors, as well as increases in the amount of sexual content in the media, have increased the need for effective promotion of healthy sexual behaviors among youth in Russia today. Effective communication and education and age-appropriate discourse on sexuality and health can alleviate fears that families may have regarding school-based education on sexual issues and reduce risks among young adults. To assess the need for more information about sex education in schools, as well as linkages with reproductive health, the RURHS11 included questions about attitudes toward sex education and actual experience of young adults with family life education in school settings. Findings: • A large majority of women aged 15–44 (88%) supported sex education in schools. Half of women interviewed thought that information about childbearing should start before age 14; 44% believed it should start between 14–15 years of age. Only 7% held the opinion that waiting until age 16 years or later was the most appropriate (Figure 14.1). • Among young women 15–24 years of age, 92% had spoken with a parent about at least one sex education topic. A large majority (88%) reported having discussions about the menstrual cycle, and almost half 0 10 20 30 40 50 60 70 80 90 100 50 43 43 44 48 48 7 9 9 16 Yrs or Older 14-15 Yrs 13 Yrs or Younger Figure 14.1 Perceived Best Age to Start Family Life Education about Specific Topics, Women Age 15-44 Pregnancy Contraception STIs Figure 14.3 Young Women Aged 15-24 Who Had Received Information about Contraception in School-Based Family Life Education, by Wealth Quintile 34 43 49 47 52 0 10 20 30 40 50 60 Lowest 2nd 3rd 4th Highest Wealth Quintile 37 Figure 14.5 Knowledge About Modern Contraceptive Methods Among Young Adults 15-24, According to Whether They Discussed Contraception With a Parent or Received Information in School 8 14 17 21 34 48 65 86 12 18 22 25 40 56 78 10 16 19 22 37 52 71 0 20 40 60 80 100 Total Knew Method Discussed Contraception with a Parent Received Information in School 89 Condoms 92 Pills IUD Emergency Contraception Female Sterilization Vaginal Methods Vasectomy Injectibles Chapter 14: Family Life Education had discussed contraceptive methods or STIs (Figure 14.2). Young women who were sexually experienced were slightly less likely to have spoken with a parent about how pregnancy occurs (55%) and HIV/AIDS (52%) compared to those who had never had sex (59% and 60%, respectively). • The large majority (90%) of respondents aged 15–24 years reported having had at least one school-based course that addressed at least one of the sex education topics. Respondents living in Moscow were somewhat more likely to have had such courses (95%) than those living in other large cities (87%) or in rural areas (88%). Women in the lowest wealth quintile reported the least exposure to almost all sex education topics, with only 34% having received information in a school setting about contraception, compared to 52% of women in the highest wealth quintile (Figure 14.3). • When asked who they felt was their most important source of information on sexual matters, young women most often stated that it was a parent (34%) or a friend (20%) (Figure 14.4). Just over 1 in 10 young women reported that the most important source had been a doctor or nurse or books or other printed materials. Surprisingly, given that almost 90% of young women had received sex education in a school setting, only 8% reported that a teacher was the most important source. Very few young adult women described their partner/boyfriend as the most important source (2%). Figure 14.4 Most Important Source of Information About Sexual Matters Reported by Young Adults 15-24 34% 20% 12% 11% 8% 8% 4% 2% 1% Parent Friends Doctor Books Teacher Internet Radio/TV Boyfriend Other • Among young adults, the most widely known methods were condoms (89%), pills (71%), withdrawal (58%), and IUDs (52%). In contrast, knowledge of injectibles (10%), vasectomy (16%), and spermicides (19%) were relatively low. Just over one in three young adults knew about emergency contraception, a relatively low level of knowledge given that unplanned sexual intercourse and unintended pregnancy are not uncommon among young adults (Figure 14.5). 38 Chapter 14: Family Life Education • For all modern methods, knowledge was greater among women who had spoken with a parent about contraception. Having been taught about contraception in school was associated with slightly lower knowledge (Figure 14.5) 39 Figure 15.3 Reported Contraceptive Use at First Sexual Experience of Women Aged 15–24 Years 41% 53% 2% 4% Did not Use Condoms Other modern Withdrawal Figure 15.2 Sexual Experience among Women Aged 15–24 Years, by Age Group 100% 80% 60% 40% 20% 0% Never had sex First sex marital 15-17 18-19 20-21 22-24 85 46 22 8 1 4 9 15 53 74 83 First sex premarital Chapter 15: Young Adult Reproductive Health Chapter 15: Young Adult Reproductive Health Young adulthood, defined in the RURHS11 as ages 15 to 24, is the period when most people begin sexual activity. Previous research in Russia has indicated that most young adults become sexually active around 17–18 years of age, and that premarital sexual activity is extremely common. Evidence also suggests that availability of clinical services that can provide adequately for the contraceptive and educational needs of sexually active young adults are not sufficient to meet the existing needs, particularly in the public sector. In order to explore the experience of young adults in Russia, the RURHS11 included a module that was administered to adolescent and young adult women aged 15–24 years to assess their sexual and reproductive behaviors, particularly the risk for unplanned pregnancy and sexually transmitted infections. Findings: • By age 17, one quarter of Russian young adults reported having initiated sexual experience (defined as having ever had sexual intercourse). The proportion increased to 42% by age 18, and to 61% by age 19 (Figure 15.1). The vast majority of young adult first sexual experiences were premarital, regardless of the age when first experience occurred (Figure 15.2). • Fifty-nine percent of sexually experienced young women ages 15–24 reported that they or their partner used some form of contraception at the woman’s first intercourse. The overwhelming majority Figure 15.1 Percentage of Young Adult Women Who Became Sexually Experienced before Given Ages P er ce n t Se xu al ly A ct iv e 0% 20% 40% 60% 80% 100% <15 <16 <17 <18 <19 <20 <21 <22 <23 <24 Age (Years) 40 Figure 15.5 Contraceptive Use at Most Recent Intercourse Among Sexually Active Women Aged 15–24 Years, by Method 80 60 40 20 0 All Married Unmarried 62 48 75 47 30 64 11 13 82 4 1 9 12 Any Modern Method Condoms Oral Contraceptives IUD Withdrawal 7 Chapter 15: Young Adult Reproductive Health of these used condoms (53% of all experienced young women), with very few reporting use of other modern methods (2%) or withdrawal (4%). However, 41% of young adults did not use any method at first sexual intercourse (Figure 15.3). • Among those who did not use contraception at first intercourse, the main reasons given were that they did not expect to have sex (47%), they did not think about using a method (20%), they wanted to get pregnant (9%), that it was a safe time of the month (7%), and that they were embarrassed to use a method (5%). Those who were married at the time of first intercourse most frequently cited wanting to get pregnant, whereas unexpected sexual intercourse was the main reason given by large majority of women whose first experience was premarital (Figure 15.4). • Over half of sexually experienced women aged 15–24 reported current sexual activity (53%), including 81% of currently married young adult, 84% of previously married women, and 34% of never married women. • Among currently sexually active young women, the RURHS11 found relatively high rates of contraceptive use at most recent intercourse, with 62% reporting use of a modern contraceptive method at their most recent sexual encounter, (Figure 15.5), and more specifically, 47% having used a condom. Oral contraceptives (OCs) were the second most frequently used method by young adults, with 11% reporting OC use at the time of their most recent intercourse. 3% 51% 21% 2% 5% 18% Wanted to get pregnant Sex was unexpected Did not think about it Did not know about it Embarrased Other Reasons Figure 15.4 Most Commonly Cited Reasons for Not Using Contraceptives at First Sexual Intercourse among Young Adult Women Aged 15–24 Years When First Intercourse Was Premarital When First Intercourse Was Marital 57% 10% 10% 5% 18% Figure 15.6 Agreement with Statements about How Women Would Feel if Partner Suggested Condom Use, According to Ever Use of Condoms, Among Sexually Active Women Ages 15-24 5 6 20 75 90 19 20 36 63 70 7 7 22 74 87 Feel I had done something wrong Insulted or angry Suspicious of him Feel safe from HIV/STI Feel safe from Pregnancy Total Never Used Ever Used 41 Chapter 15: Young Adult Reproductive Health Among unmarried young women who use contraceptives, 75% use modern methods, principally condoms (Figure 15.5). would feel suspicious of their partner if he suggested that they use condoms and few reported that they would feel insulted or angry (7%), or that they had done something wrong (7%) (Figure 15.6). • Sexually experienced young women were asked if they agreed with specific statements about their partner or husband wanting to use a condom. Almost 9 in 10 sexually experienced young adult women stated that using a condom would make them feel safe from getting pregnant. Almost three-quarters of women said they would feel safe from getting a STI or HIV/AIDS. Only 22% reported that they • Sixty-two percent of sexually experienced young adult women in Russia reported having more than one sexual partner during her lifetime. Twenty-five percent reported three or more lifetime partners. Fifteen percent of sexually experienced young women reported having had two or more partners during the past twelve months. 42 P er ce n t Figure 16.1 Awareness of Selected Sexually Transmitted Infections (STIs) Among Women Aged 15–44 Years, by Education Syphilis Gonorrhea Chlamydia Trichomoniasis Genital Herpes 99 9897 97100 80 60 40 20 0 Total < Secondary Secondary Technicum University Complete 87 91 65 87 95 96 78 39 67 84 87 75 35 67 82 81 72 38 61 77 81 Education 35 60 38 30 29 30 50 32 49 53 57 54 8 2 6 11 8 11 1 0 1 1 1 16 7 6 5 5 5 0 20 40 60 80 100 Total 0 1 2 3 4+ No Risk at All Low Risk Moderate Risk High Risk Doesn't Know Number of Lifetime Sexual Partners Figure 16.2 Perceived Risk of Contracting an STI Among Women Aged 15–44 Years, by Number of Lifetime Sexual Partners P er ce nt 25 14 32 26 26 19 11 24 21 18 6 2 9 5 7 3 1 4 2 22 1 3 1 2 1 1 2 1 10 0 1 0 0 0 5 10 15 20 25 30 35 Total 1 2 3 4+ At least 1 STI Yeast Infection Chlamydia Trichomoniasis Genital Herpes Gonorrhea Syphilis Number of Lifetime Sexual Partners Figure 16.3 Percent Who Have Been Told They Have an STI Among Women Aged 15–44 Years, by STI and Number of Lifetime Sexual Partners P er ce nt Chapter 16: Sexually Transmited Infections Other Than HIV/AIDS Chapter 16: Sexually Transmitted Infections Other Than HIV/AIDS Women suffer more frequent and severe long- term consequences from most sexually- transmitted infections (STIs) than men do: chlamydial and gonococcal infections are important causes of pelvic inflammatory disease, ectopic pregnancy, and infertility. An STI during pregnancy can lead to premature rupture of membranes, premature labor, and postpartum endometritis. The RURHS 2011 documented STI knowledge, attitudes, perception of risk, prevalence of testing for STIs, and experience of STI symptoms among a representative sample of sexually active women of reproductive age. This information provides a scientific basis for policy recommendations concerning STI prevention and management. Findings: • Survey respondents were asked if they had ever heard of six specific STIs that are common in Russia. Almost all women (98%) had heard of at least one STI. Levels of awareness of specific infections varied, ranging from a high of 97% for syphilis to a low of 72% for genital herpes (Figure 16.1). There was virtually no difference in knowledge between urban and rural areas. However, education was an important factor, with greater knowledge of virtually all STIs among more educated women. A knowledge gap was also found between those with sexual experience (99% knew of at least one STI) and those with no experience, although even 91% of the latter knew of an STI. 43 Chapter 16: Sexually Transmited Infections Other Than HIV/AIDS • Women who were aware of at least one STI symptom were asked to rate their own risk of contracting an STI. About one-third of women believed themselves to be at no risk of contracting an STI (Figure 16.2). Fifty-nine percent believed they had some risk, but most felt that their risk was low (only 1% of all women thought they were at high risk, and 8% thought they were at moderate risk). Perception of risk increased with the number of sexual partners; however, 30% of women with 2 to 4 partners thought they had at no risk at all of contracting an STI. • One-quarter of sexually experienced women reported having been told by a doctor that they had at least one STI other than HIV/AIDS (Figure 16.3). The survey found that 19% of women had experienced yeast infections (which are not always sexually transmitted) and 6% chlamydia, with one quarter of sexually active women having had one of these two. Few women reported cases of trichomoniasis (3%), genital herpes (2%), gonorrhea (1%), or syphilis (0.3%). Rates of most infections were higher among women with 2 or more lifetime partners compared to those with only one. Women who were aware of at least one type of STI were asked to name the most important source of information about STIs. Forty percent of women stated that a health professional was their primary source, with considerably fewer getting information from sources such as print media (13%), television (11%), the Internet (9%), or specialty books (8%) (Figure 16.4). The Internet was a greater source of information for urban women, those under age 25, those with the least education, those with higher socioeconomic status, and those with no sexual experience. In addition to the Internet, the younger age groups were more likely to get information on STIs from a parent or teacher, whereas the older age groups more often cited print media, TV, and specialty books as the most Figure 16.4 Principal Source of Information About STIs Among Women Aged 15–44 Years Health Professional 40%Print Media 13% TV 11% Internet 9% Books 8% Parent 6% Friend 6% Teacher 4% Other 3% important source of information. 44 77 Figure 17.1 Correct Knowledge about HIV/AIDS Among Women Aged 15–44 Years 100 87 86 Have Heard of Know that Know that no Know that Know that HIV/AIDS HIV/AIDS can cure exists for HIV/AIDS can drugs exist to be prevented HIV/AIDS be reduce mother- asymptomatic to-child transmission of HIV/AIDS 40 Figure 17.3 Location of Last HIV Test Among Women Aged 15–44 Years Who Have Ever Been Tested HIV Center 3% Private Clinic STI Disp. Polyclinic 44% Women's Consultation Clinic 43% Government Hosp. 5% 3% 2% Chapter 17: HIV / AIDS Chapter 17: HIV / AIDS The RURHS11 asked women questions about various HIV/AIDS-related topics, including knowledge of the disease and modes of transmission, as well as ways of preventing transmission of the virus. Women were asked where they had received information about HIV/AIDS, whether they knew of places that provided HIV testing, and whether they had been tested. They were also asked to assess their own risk of contracting HIV/AIDS. Findings: • In Russia, awareness of HIV/AIDS among women aged 15 to 44 years was universal (99.7%) (Figure 17.1). Overall, the great majority of women surveyed knew that no cure exists for AIDS (86%) and that there are ways to prevent transmission of HIV (87%). This knowledge generally increased with age, education level, and sexual experience. Three-quarters of respondents (77%) were aware that a person can be infected with HIV and be asymptomatic or not show any clinical symptoms of the disease. Less than half of the women (40%) knew of the existence of drugs that can reduce the likelihood of mother-to-child transmission of HIV (MTCT). • The vast majority (91%) of respondents knew of at least one place where HIV tests were provided (Figure 17.2). Women aged 15-19, the least educated, and those with no sexual experience were the least likely to know where testing is provided (68- 69%). Over two–thirds of women (68%) had been tested for HIV at some time and received results. Almost a quarter of women 91 68 24 81 Knows of at least one HIV testing place Ever tested for HIV and received results Tested for HIV and received results in past 12 months Tested for HIV and received results during ANC among women who gave birth in past 2 years Figure 17.2 Knowledge and Experience of HIV Testing Among Women Aged 15–44 Years and Testing During ANC Among Women who Had a Birth in the Past 2 Years 45 Figure 17.4 Media Source for Information on HIV/AIDS Received in the Past 6 Months Among Women Aged 15–44 Years Only TV TV/Newspaper Radio/TV/Newspaper Radio and TV Only Newspaper Other None 7 4 2 16 18 23 30 Figure 17.5 Percent of Women Aged 15–44 Years Who Spontaneously Named Methods of Preventing HIV Transmission Use condoms Have only 1 partner Do not share razors/syringes Avoid sex with IV drug users Limit number of partners Avoid blood transfusions Avoid sex with prostitutes Abstain from sex No sex with persons who have many partners Avoid injections Ask partner to get tested for HIV Avoid sex with bisexuals 9 16 19 21 22 23 26 30 37 46 56 78 Figure 17.6 Percent of Women Aged 15–44 Years Who Spontaneously Named Three Principal Methods of Preventing HIV, and Percent Who Agreed When Prompted Spontaneously named Agreed when prompted P er ce n t 100 80 60 40 20 0 78 56 22 89 93 81 Use Condoms Have 1 partner Abstain from sex Chapter 17: HIV / AIDS (24%) had been tested in the year preceding the survey. Among women who had given birth in the last two years, 81% reported having been tested for HIV and received the results over the course of their antenatal care. • Of the respondents who were ever tested for HIV, almost equal proportions had the test done in a Polyclinic (44%) or in a Women’s Consultation Clinic (43%) (Figure 17.3). Polyclinics were more favored in rural areas (49%), and women’s consultations in urban areas (45%). Although 12% of respondents had mentioned HIV Centers a known source of testing, only 3% of those tested had gone to an HIV Center, and an equally low percentage (3%) had gone to an STI dispensary. A slightly greater percentage (5%) had gone to a government hospital. • Women were asked about the media sources through which they had received information about HIV/AIDS. Most women cited television, either alone (30%), in combination with newspapers (23%), in combination with the radio (16%), or in combination with both newspaper and radio (18%) (Figure 17.4). Only 7% of women reported not having heard about HIV through some media source. • Women were questioned about their knowledge of ways to prevent the transmission of HIV/AIDS. More than three-quarters identified use of condoms (78%), and over half identified only having one sex partner (56%) as preventive measures (Figure 17.5). Also frequently cited were not sharing razors, needles, or 46 Figure 17.7 Self-Perceived Risk of Getting HIV/AIDS Among Women Aged 15–44 Years High Risk 1% Moderate Risk 7% Low Risk 53% No Risk at All 34% Don't Know 5% Chapter 17: HIV / AIDS syringes (46%) and avoiding sex with persons who use intravenous drugs (37%). • Women who did not spontaneously mention three effective prevention methods (condom use, having only one partner, and abstaining from sex), were prompted by asking whether they thought the methods were effective. Knowledge of use of condoms and of having only one partner as a means of HIV prevention was high, both in spontaneous and prompted answers (Figure 17.6). Abstaining from sex, however, was mentioned spontaneously by only 22% of women compared to 81% agreement with this method of prevention after prompting. • When asked to assess their level of risk for acquiring HIV/AIDS, one in three women (34%) thought that they had no risk at all (Figure 17.7). Over half (53%) felt that they had low risk of getting infected, 7% moderate risk, and 1% high risk. More likely to think they some risk of acquiring HIV/AIDS were women who: reside in urban areas and were older, more educated, and in the higher wealth quintiles. 47 Figure 18. 1 Reported Lifetime and Recent (Past Year) Experience of Intimate Partner Violence, by Type, Among Ever-Married Women Aged 15–44 50 40 P er ce nt 30 20 38 18 20 6 Lifetime 4 1 Past 12 Months 10 0 Verbal Abuse Physical Abuse Sexual Violence Figure 18.2 Reported Lifetime Abuse by Type of Abuse and Educational Attainment Among Ever-Married Women Aged 15–44 Years 50 40 30 20 10 0 45 42 41 34 30 25 22 16 8 6 5 2 Verbal Abuse < Secondary Physical Violence Secondary Complete Technicum Sexual Violence University Figure 18.3 Help-Seeking by Ever-Married Women Aged 15–44 Years Reported Lifetime Physical or Sexual Intimate Partner Violence, by Source of Help 53% 43% 23% 21% 10% 6% 2% 26% Friends Mother Husband's Relative Police Health Lawyer Did Not Family Provider Tell Anyone or Seek Help Chapter 18: Violence Against Women Chapter 18: Violence Against Women Over the past three decades, researchers, women’s organizations, governments, and the broader international community have increasingly recognized violence against women as a public health problem and a barrier to economic development. The RURHS11 included a series of questions to assess the burden of domestic violence in Russia and its impact on reproductive health. The questions, which focus principally on intimate partner violence (IPV), explore acts of violence perpetrated by current and former husbands and male partners with whom the respondent had lived together as a couple at some point. Findings: • More than 1 in every 3 Russian women (38%) reported lifetime verbal abuse, 1 in 5 reported lifetime physical abuse (20%), and 4% reported having been forced to have sex by a current or previous partner. Current levels of violence (occurring in 12 months prior to the survey) included: 18% verbal abuse in the past 12 months; 6% recent physical partner violence, and around 1% reported having recently experienced sexual violence (Figure 18.1). • Both lifetime and recent violence tended to be lower as educational level of the woman increased. Women with a university education had almost half the level of lifetime and current physical violence compared to women who did not complete secondary school (Figure 18.2). Women with incomplete secondary education reported the highest levels of current 48 Figure 18.5 Gender Aspects Reported by Women Concerning Their Current or Most Recent Husband or Partner’s Behavior 51% 40% 32% 19% 10% 9% Husband shares Husband insists He always wants He gets angry if He tries to limit He is frequently household chores on knowing the final say she speaks with contact with suspicious of her where she is other man family/friends Figure 18.6 Percent of Women Aged 15–44 Years Who Reported Recent Physical or Sexual Intimate Partner Violence According to Partner’s Frequency of Drunkenness 25 20 15 10 5 0 Never Occasionally 1-3 Times Once or Daily or Monthly twice weekly almost daily Frequency of Partner Drunkenness 2 4 5 13 19 Figure 18.4 Most Important Reasons for Not Seeking Help Among Ever- Married Women Aged 15–44 Years Who Reported Lifetime Physical or Sexual Intimate Partner Violence Injury Not Severe No Use/Won't Help Embarrassed Hurt Family Name Fears Divorce/Separation Fears More Violence 27% 24% 16% 8% 6% 5% Chapter 18: Violence Against Women verbal abuse (22%) and physical violence (12%) compared to any other category in the analysis. • Women who had ever experienced physical violence from an intimate partner were asked whether they told anyone about this abuse, and if so, where they turned for help. Almost three-quarters of physically abused women had spoken to someone about the violence, whereas 26% of abused women had told no one about the problem. Of these, the large majority (73% combined) sought help from family members or friends, while much smaller proportions sought help from institutional sources: police (10%), health care provider (6%), or legal advisor (2%) (Figure 18.3). • Among the 87% of women who experienced physical violence but did not seek help from police, a medical, or legal source, the largest proportion (27%) reported that the injury was not severe enough to warrant seeking care. This was followed by 24% who felt that seeking services would not do any good; 16% who felt embarrassed to seek assistance; 8% who thought that seeking assistance would negatively affect the family name; 6% who were afraid of separation/divorce or of losing the children; and 5% who were afraid that reporting the violence might cause further beatings, punishment, or blame (Figure 18.4). • When asked about gender attitudes and norms in her current or most recent relationship, half of Russian women reported that their husbands usually shared in household chores (51%) (Figure 18.5). 49 Figure 18.7 Percent of Women Who Witnessed Physical Violence Between Parents During Childhood, According to Experience of Physical or Sexual Intimate Partner Violence as an Adult All women Women with no partner violence Women who experienced partner violence 18% 22% 45% 0 10 20 30 40 50 % Who Witnessed Parental Violence Chapter 18: Violence Against Women Women’s education was positively associated with a more equitable sharing of household chores, with 54% of women with university education reporting sharing, compared to 44% of women with incomplete Secondary education. However, gender norms associated with increased levels of domestic violence were also common: More than one in every three women reported that their husband insists on knowing where they are at all times (40%); 32% reported that their husband wants to have the final say; 19% stated that their husband gets angry if she speaks with another man; 10% reported that their husband tries to limit contact with their family or friends; and 9% reported that their husband is frequently suspicious that they are unfaithful. • Worldwide, alcohol use is one of the most consistently identified risk factors for intimate partner violence. The RURHS11 asked women who had been married or in a consensual union during the past 12 months how frequently their partner becomes drunk on alcohol. Recent physical or sexual violence was reported by 19% percent of women whose husbands were drunk almost every day or more, and by 13% those whose husbands were drunk once or twice a week, compared to only 4% of women whose husbands were occasionally drunk and to 2% of those whose husbands were never drunk (Figure 18.6). • Childhood exposure to violence is also a well-established risk factor for intimate partner violence later in a woman’s life. In the RUHRS11, 22% of women reported having heard or seen abuse between their parents when they were children. Among women who reported in the RURHS11 that they had been physically or sexual abused by an intimate partner as an adult, almost half (45%) reporting having witnessed abuse in their childhood home compared to 18% among women who had not experienced intimate partner violence (Figure 18.7). 50 Figure 19.1 Knowledge of Treatment Services for Infertility Among Women Aged 15-44, by SES Region 100 81 86 85 81 7880 P er ce n t 60 40 20 0 SES Region Figure 19.2 Percent Ever Diagnosed for Infertility Among Ever Married Women Aged 15-44, by SES Region and Age Group 10 8 6 4 5 4 4 4 2 1 6 4 P er ce n t 2 0 SES Region Maternal Age P er ce n t Figure 19.3 Percent Diagnosed With Infertility Problems Among Ever Married Women Aged 15-44 40 36 30 28 18 15 30 20 10 0 Ovulation Blocked Tubes Semen/sperm Endometriosis Other Problem Problem Medical Diagnosis Chapert 19: Infertility Chapter 19: Infertility Infertility is often cited as a reproductive health concern in Russia, given the low fertility, widespread use of abortion, and increase in sexually transmitted diseases (STIs) and cases of pelvic inflammatory disease (PID). In order to obtain national data on infertility and receipt of infertility services, the RURHS11 included a series of questions about knowledge and use of services, diagnoses, and treatment received. Findings: • Over 80% of women knew of a place where women can seek diagnosis or treatment for helping them to become pregnant (Figure 19.1). The proportion of women who knew of a diagnosis and treatment site was slightly higher in urban than in rural areas. • Four percent of ever married women aged 15-44 said that they or their partner had been diagnosed with infertility (Figure 19.2). The percent of women that was ever diagnosed with infertility was lower in Moscow compared to other areas, and as expected, the percent that had sought diagnosis was greatest among women aged 35-44 (6%). • Among the 4% of women who were diagnosed with infertility, 36% percent were diagnosed with ovulation problems, 30% with blocked tubes, 28% with semen or sperm problems, 18% with endometriosis, and 15% with other conditions that affected their fertility (percentage does not sum to 100% because multiple diagnoses may have been mentioned). 51 Reproductive Health Survey Russia 2011 This summary report was funded by the United Nations Population Fund (UNFPA). Table of Contents Chapter 1: Introduction 1 Chapter 2: Methodology 4 Chapter 3: Characteristics of the Sample 6 Chapter 4: Fertility 7 Chapter 5: Induced Abortion 10 Chapter 6: Maternal and Infant Health 14 Chapter 7: Contraceptive Knowledge 18 Chapter 8: Current and Past Contraceptive Use 21 Chapter 9: Need for Contraceptive Services 25 Chapter 10: Contraceptive Counseling 27 Chapter 11: Opinions About Contraception 29 Chapter 12: Reproductive Health Knowledge and Opinions 32 Chapter 13: Women’s Health 34 Chapter 14: Family Life Education 37 Chapter 15: Young Adult Reproductive Health 40 Chapter 16: Sexually Transmitted Infections Other Than HIV/AIDS 43 Chapter 17: HIV / AIDS 45 Chapter 18: Violence Against Women 48 Chapter 19: Infertility 51 1.1 Background 1.2 Objectives 2.1 Sampling Design 2.2 Data Collection 2.3 Response Rates Findings: Findings: Findings: Findings: Findings: Findings: Findings: Findings: Findings: Findings: Findings: Findings: Findings: Findings: Findings: Infertility is often cited as a reproductive health concern in Russia, given the low fertility, widespread use of abortion, and increase in sexually transmitted diseases (STIs) and cases of pelvic inflammatory disease (PID). In order to obtain nation. Findings:

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