1993 Contraceptive Prevalence Survey Jamaica Volume III Sexual Experience Contraceptive Practice and Fertility

Publication date: 1994

CONTRACEPTIVE PREVALENCE SURVEY JAMAICA 1993 VOLUME III SEXUAL EXPERIENCE, CONTRACEPTIVE PRACTICE AND FERTILITY Carmen P. McFarlane, M.Sc. (Econ.) Jay S. Friedman, M.A. Leo Morris, Ph.D., M.P.H. Howard I. Goldberg, Ph.D. NATIONAL FAMILY PLANNING BOARD October 1994 PRINTED BY: U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention Atlanta, Georgia 30333 PREFACE The 1993 Jamaica Contraceptive Prevalence Survey (CPS) is the fifth in a series of periodic enquiries conducted by the National Family Planning Board (NFPB). The Survey seeks to update measures of fertility and contraceptive use among women aged 15-44 years and, for the first time, included a special module for men aged 15-54 as well as for young adults (male and female) aged 15-24 years. The scope of the survey, as in earlier studies, is designed to gather information on a broad range of areas including knowledge, attitudes and practices in contraception; perceptions on the role of men and women, including views on sexuality, child bearing, child rearing and health care. This CPS, coming as it does in the last decade of the century, is of significance to the NFPB in particular and the wider community in general, as it heralds the beginning of the twenty first century and the realization of the goals of Jamaica's National Population Policy. It also comes against the gradual phased withdrawal of contraceptive procurement by the major funding agency, the United States Agency for International Development (USAID), by a twenty percent (20 percent) annual decline over the period 1993-1998 under the Family Planning Initiatives Project (FPIP), as well as the phased diminution of funding from other donor agencies such as the United Nations Fund for Population Activities (UNFPA). This CPS is in fact one of two surveys to be conducted during the life of the FPIP. Against this background, the NFPB has many challenges ahead which are, inter alia, not only to maintain but also to increase contraceptive prevalence and to achieve further milestones by the inception of the twenty-first century, such as a population of not more than 2.7 million and replacement level fertility of two children per woman. For contraceptive methods and family life services to impact on fertility and contribute to the processes of national development, it is vital that programme effectiveness be evaluated. The reliable and current data collected from the CPS will be of invaluable use in policy analysis and programme implementation for administrators and planners, not only in health but in those areas which impact on population issues at the broader national level. The Final Report of the 1993 CPS is presented in the following five volumes: I Administrative Report II Knowledge Of and Attitudes Towards Family, Contraception and AIDS III Sexual Experience, Contraceptive Practice and Reproduction IV Sexual Behaviour and Contraceptive Use Among Young Adults V Profiles of Health Regions In addition, an Executive Summary, containing a summary of the main findings of the Survey will be presented. Volume I - the Administrative Report, contains background information on historical, geographical, demographic and social features relating to Jamaica and its population as well as the relationship of the Survey data to the population policies and programmes being implemented by the Government. In addition, the survey design and organization including the sample design as well as the outcome of the data collection are presented. Background variables used in the exposition of the data are also displayed. Finally, a summary report on the National Dissemination Seminar together with recommendations made by participants are included. Volume II presents data on knowledge of and attitudes towards family, contraception and AIDS of women aged 15-44 years and men aged 15-54 years while Volume III contains information on their sexual experience, contraceptive practice and reproductive history. Volume IV is dedicated to young adults, female and male, aged 15-24 years and in particular to their sexual behaviour and contraceptive use. The last volume, Volume V, presents selected information at the health region level so as to assist planners to determine the success or otherwise of the programmes being provided in each of the four health regions. The 1993 CPS was funded by USAID and directed by Mrs. Carmen McFarlane, Survey Director, a former Director General of the Statistical Institute of Jamaica (STATIN), in collaboration with NFPB and the Ministry of Health, while field work and data entry were carried out by STATIN. Technical assistance was provided by the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC) in the areas of survey design and sampling, questionnaire development and training, data processing and report preparation. STATIN and CDC were jointly responsible for printing. The National Family Planning Board wishes to place on record its sincere thanks to all those organizations which participated in the planning of the Survey, the development of the questionnaire and the review of the various modules. Main participants were the Ministry of Health, the Statistical Institute of Jamaica, the Planning Institute of Jamaica and the Fertility Management Unit of the University of the West Indies. Special acknowledgements are due to Mr. Vernon James, Director General, STATIN, for his leadership and support of STATIN's participation in the Survey; Miss Isbeth Bernard, Director of Surveys, for supervision of the field work and data entry, Mrs. Valerie Nam, Director of Censuses & Related Studies and Mrs. Merville Anderson, Senior Statistician, for their assistance in training on the questionnaires, all of STATIN; and to Ms. Margaret Watson and Mr. Daniel Wallace, computer specialists of CDC, for installation of the data entry/edit software and training of STATIN personnel in its use. The NFPB also wishes to thank all who participated in the development, implementation and finalization of the survey. Particular mention is made of Mrs. Carmen McFarlane, Survey Director; Dr. Leo Morris and Mr. Jay Friedman of CDC; Mrs. Betsy Brown, Director, Office of Health, Nutrition and Population and Mrs. Grace Ann Grey, Project Officer, both of US ADD; Dr. Sheila Campbell-Forrester, SMO, Cornwall Regional Hospital, Dr. Beryl Irons, SMO/MCH, Drs. Peter Weller and Peter Figueroa of the Epidemiology Unit and Ms. Kristin Fox, Director, Health and Information Unit, of MOH; Dr. Olivia McDonald, Medical Director, Mrs. Eugenia McFarquhar, Family Planning Co-ordinator, Mrs. Ellen Radlein, Director, Projects & Research, Mrs. Janet Davis, Director, Information, Education & Communication, and Mrs. Marian Kenneally, Programme Co- ordinator, of the NFPB. Finally, to the more than 7,000 women and men who gave up their time to answer so many questions, we owe a debt of gratitude for this information, which we are sure will be useful in enhancing their lives. Beryl Chevannes, Executive Director. August, 1994. CONTENTS LIST OF TABLES ix III.1 - BACKGROUND 1 III.2 - SEXUAL EXPERIENCE 3 III.2.1 History of sexual experience 3 III.2.2 Current sexual activity 4 III.3 - CONTRACEPTIVE USE 5 III.3.1 Ever use of contraceptives 5 III.3.2 Current use of contraceptives 8 III.3.3 Continuation and non-use of contraception 15 III.3.4 Sterilization - use and demand 17 III.3.5 Women and men in need of family planning 19 III.4 - AVAILABILITY AND COST OF CONTRACEPTIVE SERVICES 21 III.4.1 Source of contraception and distance from source 21 III.4.2 Willingness to pay for contraception 22 III.5 - FERTILITY AND FERTILITY-RELATED SERVICES 23 III.5.1 General factors affecting fertility 23 III.5.2 Planning status of last pregnancy / birth 23 III.5.3 Current fertility estimates 25 III.5.4 Breastfeeding and postpartum insusceptibility 26 III.5.5 Maternal health and child care 28 NOTES 30 TABLES LIST OF TABLES 2.1.1 Percent Of Women Aged 15 to 44 Who Have Ever Had Sexual Relations By Selected Characteristics And Compared To 1989 CPS 2.1.2 Percent Of Men Aged 15 to 54 Who Have Ever Had Sexual Relations By Selected Characteristics 2.1.3 Percentage of Women 15-44 Who Have Had Their First Sexual Relation And Their First Birth Before Selected Ages, By Current Age Group 2.1.4 Percentage of Men 15-54 Who Have Had Their First Sexual Relation And Fathered Their First Child Before Selected Ages, By Current Age Group 2.2.1 Percentage of Women 15-44 Who Are Currently Sexually Active And Percent Distribution Of Frequency Of Sexual Relations, By Relationship Status 2.2.2 Percentage of Men 15-44 Who Are Currently Sexually Active And Percent Distribution Of Frequency Of Sexual Relations By Relationship Status 2.2.3 Relationship With Last Sexual Partner By Current Relationship Status (Percent Distribution) Women Aged 15-44 And Men Aged 15-54 Who Are Sexually Active 3.1.1 Percent of Women 15-44 and Men 15-54 Who Have Ever Used Any Contraceptive Method By Selected Characteristics, Women Compared With 1989 CPS 3.1.2 Percent of Women 15-44 and Men 15-54 Who Have Ever Used A Contraceptive Method By Residence and Method, Women Compared With 1989 CPS 3.1.3 Mean Age (In Years) When First Used A Contraceptive Method Women 15-44 and Men 15-54 Who Have Used Contraception By Selected Characteristics, Women Compared With 1989 CPS 3.2.1 Percentage of Women 15-44 Currently Using Contraception, By Relationship Status and Method Compared With 1989 Contraceptive Prevalence Survey (Percent Distribution) 3.2.2 Percentage of Men 15-54 Currently Using Contraception By Relationship Status and Method (Percent Distribution) 3.2.3 Percentage of Women Aged 15-44 and Men Aged 15-54 Currently in a Union Who Are Currently Using Contraception, By Method Women Compared With 1983 JCPS And 1989 JCPS (Percent Distribution) 3.2.4 Percent of Women In Union Aged 15-44 Who Are Currently Using Any Contraceptive Method By Residence and Selected Characteristics Compared With 1989 Contraceptive Prevalence Survey 3.2.5 Percent of Men In Union Aged 15-54 Who Are Currently Using Any Contraceptive Method By Residence and Selected Characteristics 3.2.6 Percent of Women In Union Aged 15-44 Who Are Currently Using Any Contraceptive Method By Educational Attainment and Selected Characteristics Compared With 1989 Contraceptive Prevalence Survey 3.2.7 Percent of Men In Union Aged 15-54 Who Are Currently Using Any Contraceptive Method By Educational Attainment and Selected Characteristics 3.2.8 Percentage of Women In Union 15-44 Currently Using Contraception By Age Group and Method Compared With 1989 CPS (Percent Distribution) 3.2.9 Mean Age of Women Aged 15-44 Currently in a Union Who Are Currently Using Contraception, By Method Compared With 1989 JCPS 3.2.10 Percentage of Men In Union 15-54 Currently Using Contraception By Age Group and Method (Percent Distribution) 3.2.11 Percentage of Women In Union 15-44 Currently Using Contraception By Number Of Live Births and Method Compared With 1989 Contraceptive Prevalence Survey (Percent Distribution) 3.2.12 Percentage of Men In Union 15-54 Currently Using Contraception By Number Of Live Births and Method (Percent Distribution) 3.2.13 Percentage of Women In Union 15-44 Currently Using Contraception By Educational Attainment and Method Compared With 1989 Contraceptive Prevalence Survey (Percent Distribution) 3.2.14 Percentage of Men In Union 15-54 Currently Using Contraception By Educational Attainment and Method (Percent Distribution) 3.2.15 Percentage of Women In Union 15-44 And Men In Union 15-54 Currently Using Contraception, By Frequency Of Church Attendance And Method, (Percent Distribution) 3.2.16 Percentage of Fecund Women In Union 15-44 And Fecund Men In Union 15-54 Currently Using Contraception By Desire For More Children and Method (Percent Distribution) 3.2.17 Percentage Of Contraceptive Users Who Are Concurrently Using A Second Contraceptive Method By First Method Used And Second Method Used (Percent Distribution) Women In Union Aged 15-44 And Men In Union Aged 15-54 3.2.18 Percent of Sexually Active Men Aged 15 to 44 Who Report They Have More Than One Sexual Partner By Relationship Status And By Age Group 3.2.19 Percentage of Men Currently Using Contraception With Their Next-To-Last Sexual Partner By Relationship Status With Last Sexual Partner And Method (Percent Distribution) Sexually Active Men Aged 15-54 With More Than One Sexual Partner 3.2.20 Percentage of Men Currently Using Contraception With Their Next-To-Last Sexual Partner, By Age Group and Method (Percent Distribution) Sexually Active Men Aged 15-54 With More Than One Sexual Partner 3.2.21 Of Those Men Aged 15-54 Who Are Currently Using A Contraceptive Method With A Secondary Sexual Partner The Percentage Who Are Concurrently Using A Second Contraceptive Method With Their Secondary Sexual Partner By All First Methods Used And By First Method Use Of Condoms And The Pill 3.3.1 Contraceptive Discontinuation Rates: Proportion Of Women Aged 15-44 No Longer Using The Pill, Injectables And Condoms After 12, 24 And 36 Months By Residence 3.3.2 Reasons for Not Currently Using a Contraceptive Method, By Gender (Percent Distribution), Women Aged 15-44 And Men Aged 15-54 Women Compared With Data From 1989 CPS 3.3.3 Reasons for Not Currently Using a Contraceptive Method, By Relationship Status, (Percent Distribution) Women 15-44 Not Currently Using a Method 3.3.4 Reasons for Not Currently Using a Contraceptive Method By Relationship Status, (Percent Distribution) Men 15-54 Not Currently Using a Method 3.3.5 Reasons for Not Currently Using a Contraceptive Method, By Residence (Percent Distribution), Women 15-44 Not Currently Using a Method Compared With Data From 1989 CPS 3.3.6 Reasons for Not Currently Using a Contraceptive Method, By Residence (Percent Distribution), Men 15-54 Not Currently Using a Method 3.3.7 Reasons for Not Currently Using a Contraceptive Method By Selected Last Used Contraceptive Methods, (Percent Distribution) Women 15-44 Not Currently Using a Method 3.3.8 Reasons for Not Currently Using a Contraceptive Method By Selected Last Used Contraceptive Methods, (Percent Distribution) Men 15-54 Not Currently Using a Method 3.3.9 Reasons for Not Currently Using a Contraceptive Method By 5 Year Age Group, (Percent Distribution) Women 15-44 Not Currently Using a Method 3.3.10 Reasons for Not Currently Using a Contraceptive Method By 5 Year Age Group (Percent Distribution) Men 15-54 Not Currently Using a Method 3.3.11 Desire To Use A Contraceptive Method In The Future Women 15-44 Not Currently Using Contraception By Relationship Status and Method They Would Like To Use (Percent Distribution) 3.3.12 Desire To Use A Contraceptive Method In The Future Men 15-54 Not Currently Using Contraception By Relationship Status and Method They Would Like To Use (Percent Distribution) 3.4.1 Characteristics Of Sterilized Women Compared With Non-Sterilized Women Women In Union Aged 15-44 By Selected Characteristics Compared With 1989 Contraceptive Prevalence Survey 3.4.2 Characteristics Of Men Whose Partners Are Sterilized Compared With Men Whose Partners Are Not Sterilized Men In Union Aged 15-54 By Selected Characteristics 3.4.3 Characteristics Of Sterilized Women In Union Aged 15-44 At Time Of Sterilization Compared With 1989 Contraceptive Prevalence Survey (Percent Distribution) 3.4.4 Percentage Of Sterilized Women In Union Aged 15-44 Who Have Never Used Another Contraceptive Method Women Aged 15-44 By Selected Characteristics 3.4.5 Mean Number Of Children Ever Born To Women In Union Aged 15-44 By Age And Whether Or Not Sterilized 3.4.6 Percentage Of Sterilized Women Aged 15-44 And Men Aged 15-54 Whose Wives/Partners Were Sterilized Who Received Counselling On Sterilization, By Subject Of Counselling 3.4.7 Percentage Of Sterilized Women Aged 15-44 Who Were Not Satisfied With The Operation, By Selected Characteristics 3.4.8 Reasons Why Not Satisfied With Sterilization Women Aged 15-44 Who Were Not Satisfied With Having Been Sterilized (Percent Distribution) 3.4.9 Percentage Of Men Who Were Not Satisfied With Partner's Sterilization By Selected Characteristics Men Aged 15-54 Whose Wives/Partners Were Sterilized 3.4.10 Percentage Of Women And Men Who Are Interested In Sterilization By Selected Characteristics Women 15-44 Who Are Fecund And Men 15-54 Whose Partners Are Fecund And Who Do Not Want Any More Children 3.4.11 Reasons Why Not Sterilized Women Aged 15-44 And Men Aged 15-54 Who Do Not Want Any More Children And Who Are Interested In Being Sterilized Women By Residence, (Percent Distribution) 3.4.12 Reasons Why Not Sterilized Women Aged 15-44 Who Are Interested In Being Sterilized And Who Do Not Want Any More Children By Educational Attainment, (Percent Distribution) 3.5.1 Percent of Women Aged 15 to 44 Who Are In Need of Family Planning Services By Selected Characteristics And Compared To 1989 CPS 3.5.2 Characteristics Of Women Aged 15-44 Who Are In Need of Family Planning Services Compared To All Women 15-44, (Percent Distribution) 3.5.3 Percent of Men Aged 15 to 44 Who Are In Need of Family Planning Services By Selected Characteristics 3.5.4 Characteristics Of Men Aged 15-54 Who Are In Need of Family Planning Services Compared To All Men 15-54, (Percent Distribution) 4.1.1 Source Of Most Prevalent Contraceptive Methods By Method Currently Used And Residence, (Percent Distribution) Women In Union Aged 15-44 4.1.2 Comparative Data From 1989 CPS On Source Of Most Prevalent Contraceptive Methods By Method Currently Used And Residence, (Percent Distribution) Women In Union Aged 15-44 4.1.3 Source Of Most Prevalent Contraceptive Methods By Method Currently Used And Residence, (Percent Distribution) Men In Union Aged 15-54 4.1.4 Distance To Source Of Most Prevalent Reversible Contraceptive Methods By Method Currently Used And Residence (Percent Distribution) Women In Union Aged 15-44 4.1.5 Distance To Source Of Most Prevalent Reversible Contraceptive Methods By Method Currently Used And Residence (Percent Distribution) Men In Union Aged 15-54 4.2.1 Willingness To Pay For The Contraceptive Method They Are Using And The Amount They Would Be Prepared To Pay For Most Prevalent Reversible Contraceptive Methods By Method Currently Used, (Percent Distribution), Women Aged 15-44 4.2.2 Willingness To Pay For The Contraceptive Method They Are Using And The Amount They Would Be Prepared To Pay For Most Prevalent Reversible Contraceptive Methods By Method Currently Used, (Percent Distribution), Men Aged 15-54 5.1.1 Mean Age At First Menstrual Period Women Aged 15 to 44, By Selected Characteristics 5.1.2 Percentage of Women Aged 15-44 Who Are Childless By Current Age Group And Selected Characteristics 5.2.1 Planning Status of The Most Recent Pregnancy According to Selected Characteristics And Compared To 1989 CPS Women 15-44 Who Had a Live Birth in the Past Five Years (Percent Distribution) 5.2.2 Planning Status of The Last Child Of Men 15-54 Who Have Fathered A Child According to Selected Characteristics, (Percent Distribution) 5.2.3 Planning Status of The First Child Of Men 15-54 Who Have Fathered A Child According to Selected Characteristics, (Percent Distribution) 5.3.1 Age-Specific Fertility Rates By Maternal Age And Total Fertility Rate (TFR) For Jamaica From 1975 Fertility Survey, 1983 JCPS, 1989 JCPS And 1993 JCPS 5.3.2 Age-Period Fertility Rates By Maternal Age And Total Fertility Rate (TFR) 5.4.1 Percent Of Women 15-44 Who Had A Birth Since January 1991 Who Breast-Fed Their Last Child And Mean Duration Of Breast-Feeding, By Selected Characteristics 5.4.2 Length Of Time After The Last Birth That Breast-Feeding Began By Selected Characteristics Women 15-44 With A Birth Since January 1988 Who Breast-Fed Their Last Child, (Percent Distribution) 5.4.3 Percentage Of Women 15-44 Who Had A Birth In The 24 Months Prior To The Survey Who: 1. Are Still Breast-Feeding; 2. Are Postpartum Amenorrheic; 3. Have Not Resumed Sexual Intercourse; 4. Are Postpartum Insusceptible By Number Of Months Since The Last Birth 5.4.4 Percentage Of Women 15-44 Who Had A Birth In The 24 Months Prior To The Survey Who: 1. Are Still Breast-Feeding; 2. Are Postpartum Amenorrheic 3. Have Not Resumed Sexual Intercourse; 4. Are Postpartum Insusceptible* By Selected Characteristics 5.5.1 Percent Of Pregnancies In The Last Five Years During Which Women Aged 15 to 44 Received Antenatal Care By Selected Characteristics And Compared To 1989 CPS 5.5.2 Source Of Antenatal Care Women Aged 15-44 Who Have Had Antenatal Care In The Past Five Years By Selected Characteristics, (Percent Distribution) Total Compared To 1989 Contraceptive Prevalence Survey, 5.5.3 Number Of Visits For Antenatal Care Women Aged 15-44 Who Have Had Antenatal Care In The Past Five Years By Selected Characteristics, (Percent Distribution) 5.5.4 Percentage Of Ever Pregnant And Currently Pregnant Women Aged 15-44 Who Smoked And/Or Drank Alcohol Just Before And During Last Or Current Pregnancy By Age Group And Residence 5.5.5 Birth Attendant At Delivery Of Children Born In The Last Five Years Women Aged 15-44 Who Have Had A Live Birth In The Past Five Years By Selected Characteristics, (Percent Distribution) 5.5.6 Type Of Delivery For Children Born In A Hospital Live Births In The Last Five Years To Women Aged 15-44 By Selected Characteristics, (Percent Distribution) CHAPTER I BACKGROUND 1.1 OBJECTIVES OF THE SURVEYS AND COVERAGE The 1993 Jamaica Contraceptive Prevalence Survey programme is the most recent in the continuing series of enquiries undertaken by the National Family Planning Board, aimed at obtaining information on levels of fertility in Jamaica and on related factors which impact on the size of the population and on the rate of growth. Earlier enquiries were conducted among females in 1974, 1979, 1983 and 1989 and among males between November 1983 to April 1985, with a more restricted enquiry carried out in 1987 among males and females in the age group 14-24 years. Other studies in this field have been undertaken by other institutions, chief of which is the government's statistical agency. Estimates of fertility rates are generally available from the decennial censuses of population carried out between 1861 until 1980 by the former Department of Statistics and more recently by the Statistical Institute of Jamaica, with intercensal estimates also being provided by these institutions. In addition, a more comprehensive study, the 1975/76 Jamaica Fertility Survey was carried out within the programme of the World Fertility Survey by the former Department of Statistics. The 1993 Survey is the most comprehensive of the enquiries to be undertaken, focusing on women and men in their most active reproductive ages, with specific emphasis on young adults in the group. The main aim of the survey programme is to obtain a wide range of information on the knowledge and practices of Jamaican men and women in general and their partners in particular in all matters relating to the determination of the levels of fertility of women in the population, the number of births and efforts made (if any) to regulate the number and spacing of their children. It also aims at assessing other related health conditions covering maternal-child health and behavioural risk factors. These insights will prove invaluable for projecting as well as for revising population targets and more generally, ensuring that the necessary data exist. The extension of the coverage to include men will enlarge the information which can be used among other things to develop meaningful male responsibility programmes for controlling the birth rate in Jamaica. The Survey should provide users including decision-makers with data which will assist in the development of policies which could lead to overall reductions in the birth rate through a more efficient spacing of children. In addition to the development of policies directly concerned with population growth, a further objective of the Survey is to provide information which could contribute to an effective family life education programme within and outside the formal education system which aim at improving knowledge and practices relating to the conception and care of children. Finally, information on selected behavioural risk factors which include smoking and alcohol use during pregnancy and knowledge of transmission and prevention of AIDS, are provided with a view to contributing to the effort of minimizing the impact which such habits and/or diseases might have on the population as a whole and women in particular and in this context, providing information for the development of appropriate educational 2 programmes. The 1993 CPS covers a wide cross-section of topics which include fertility, infant and child mortality and reproductive history, contraceptive usage, attitudes towards reproduction, maternal and child health, and behavioural risks. Background characteristics relating to the demographic and socio-economic status of the population surveyed are also included. These comprise age structure, educational attainment, employment status, frequency of church attendance and union status. A new classification, socio-economic index has been developed to assist in the analysis of the 1993 survey results. This index has been developed to assess the impact of social, economic and cultural factors on the respondent population and is derived mainly from the education and occupation of the head of the household. Its relevance has also been tested on elements pertaining to household density and access to media by household members. The items used in this latter comparison are number of rooms occupied by household members, possession by members of the household of radio and television, and readership of newspapers by household members. The trends observed were analyzed on the basis of expected trends, taking into account the anticipated movement of each variable. Four ranks have been employed in setting up the index. These are: "high", "medium", "low" and "very low".1 The level of contraceptive usage will be measured against these background variables. Geographic coverage in general is national, with disaggregation at two levels - urban and rural, and health region. With respect to urban and rural distinctions, major urban areas throughout the country are identified and grouped. All other areas are classified as rural. Differentials in urban and rural areas of residence as well as by demographic and socio- economic characteristics will be identified in order to assess the impact of current programmes as well as to provide guidelines as to areas which might benefit from special or intensified program efforts.2 Data on current fertility and levels of unintended fertility will be provided as well as information on birth spacing, breastfeeding and contraceptive use. The reproductive history of men will also be included, thus giving a more complete picture of child bearing in Jamaica. The 1993 Contraceptive Prevalence Survey, in addition, provides information on current sexual activity of both men and women, particularly in relation to multiple partners and the use of contraceptives. Details should be useful to planners of programmes in STD/HIV prevention. 3 CHAPTER II SEXUAL EXPERIENCE 2.1 - HISTORY OF SEXUAL EXPERIENCE Section 2.1 examines the history of sexual experience of female and male respondents at the time of the survey, making comparisons where data permit with patterns relating to women in 1989. The percentages who have ever had sexual relations will in the first instance be identified, followed by the age at which they had such relations. Table 2.1.1 presents data for the years 1993 and 1989 on women aged 15-44 who reported that they have ever had sexual relations, by selected characteristics. Eighty-eight percent of women in 1993 reported that they have had sexual relations, slightly higher than the 86 percent in 1989 (p < 0.05). There were no significant differences between urban and rural areas in both years; however, as may be expected, there was some variation by age. Less than 60 percent of the women between ages 15-19 in both years (59 percent in 1993 and 53 percent in 1989) had already had sexual experience, but over 90 percent of the remainder had sexual experience, the percentage increasing with age. In both years women with primary education or less were more likely to have had sexual relations than those with higher levels of education. Women in the high socio-economic group report the lowest percentage of sexual experience. Results by church attendance is linear; the greater the attachment to the church based on regularity of attendance, the lower is the percentage of women who have ever had sexual relations. The percentages of men who have ever had sexual relations at the time of the survey (Table 2.1.2) is higher than for women (93 percent compared with the 88 percent for women). The patterns are, however, similar in all of the characteristics studied, although in all cases the percentages were higher. Table 2.1.3 presents data on the age at which the first sexual intercourse took place for women by five year age group. This provides an indication of trends over time of ages in which women were beginning their sexual activity. Account should be taken of the reporting by the youngest age groups which includes incomplete reporting due to their time of exposure being partially truncated. Looking at the median age at first sex (a median of 17.2 years, varying from 17.1 years to 17.5 years), only minor variations may be observed and these are not statistically significant. Percentages having had sexual relations before the indicated age groups also show minor variations over the age spectrum. It may thus be concluded that the age at which women have had their first sexual relation has changed little over the thirty year period. Table 2.1.3 also provides information on age before first birth by five year groups (current age). Results from this panel show a consistency in patterns of age at first birth, similar to those for age at first sexual relations. 4 Table 2.1.4 presents information complementary to that given in Table 2.1.3, but for men. Here, median age at first sexual intercourse is on average almost two years lower for men than for women (15.6 years for men compared with 17.2 years for women). The historical trend observed for men shows a one year decline in age at first sexual experience over the past 35-40 years. The pattern has been for men, at all ages, to start their sexual experience earlier than women. What is the experience of the men in relation to fathering their first child? The median age at birth of the first child is much higher for the four age groups that can be compared with women, with little variation over the years. On average, while one-quarter of women (24.9 percent) have had a first born child before age 18, it is only at age 25 that men approach that percentage (28.1 percent) 2.2 - CURRENT SEXUAL ACTIVITY Fifty-six percent of women reported that they had sexual intercourse at least once in the last month (Table 2.2.1). This percentage varied by relationship status. More than 80 percent of married women (86 %) and women in a consensual union (82 %) were sexually active. This percentage drops to 67 percent for women who have a visiting partner and 53 percent for those who have a boy friend. Less than two percent of women with no steady partner reported sexual activity in the last 30 days. One out of six sexually active women did not remember the number of acts of sexual intercourse they had engaged in during the last 30 days. (This response generally meant that their level of sexual activity was such that they could not remember the exact number of times.) About one-half reported up to four sexual acts in the past month, averaging once per week or less. Generally, the more stable the relationship, the greater the number of sexual acts in the past 30 days. Two-thirds (68 %) of men reported current sexual activity (Table 2.2.2). As with the female sample, sexual activity was related to the stability of the respondent's relationship. However, overall and within each relationship status, men reported a higher level of sexual activity than women. Sexually active women and men were asked the relationship they had with their last sexual partner (Table 2.2.3). Almost all legally married women (99 %) and women in consensual union (93 %) said their last sexual partner was their spouse. However, 23 percent of women in a visiting relationship and 12 percent of women with a boyfriend had sex with a different partner the last time they had sexual intercourse. The last sexual act of almost all married men (98 %) was with their spouse. Men in a common law union (89 %) and men with a girl friend (84 %) tended to have had their last sexual encounter with their primary partner. However, only 59 percent of men in a visiting relationship had sex with this partner the last time they had sex. 5 CHAPTER III CONTRACEPTIVE USE 3.1 - EVER USE OF CONTRACEPTIVES Section 3.1 examines ever use of contraception, presented in Tables 3.1.1 to 3.1.3. The first table, Table 3.1.1, looks at women aged 15-44 years and men 15-54 years who have ever used any contraceptive method by selected characteristics, comparing 1993 with 1989 for women. Seventy-nine percent of all Jamaican women aged 15-44 have ever used any method of contraception at some time, compared to 71 percent of women in 1989 (p < 0.05). there was a slightly lower level of use in rural areas (77 percent) compared to urban areas (83 percent). Ever use increases with age up to ages 25-29, remains steady and then declines after the age of 40, similar to the pattern of ever use in 1989. Ever use was lowest for the 15-19 age group. The lower use by teenagers is correlated with the approximately 50 percent ever use reported by women with no live births and/or no current partner. Only 51 percent of women with no live births ever used contraception, compared to 89 percent or more of women with one or more live births. Over 91 percent of women currently in union (married, common law or visiting partner) have ever used contraception, but only 50 percent of women not currently in union have ever used. Women with secondary education have the lowest ever use (75 to 77 percent) while the two extreme education groups have a higher level of 84 percent. Ever use of contraception does not vary by socio-economic groups, although it rises with decreasing frequency of church attendance. Eighty-two percent of all Jamaican men aged 15-54 report that they or their partners have used a method of contraception at some time. The patterns of use among men are similar to those of women, except a higher percentage of men than women under the age of 25 have ever used a method. As will be seen in later sections of this report, this is due to the high level of condom use among young men. Ever use of specific methods by residence is shown in Table 3.1.2 for men and women, with women compared to 1989. For women, in 1993, the most prevalent modern method ever used was the condom (53 percent), followed closely by the pill (51 percent), with injectables (24 percent) and female sterilization (10 percent) in third and fourth positions, respectively; twenty percent of women report the use of withdrawal during their lifetime. The same four modern methods were the most prevalent ever used in both urban and rural areas. Except for slightly higher ever use of the IUD in urban areas and slightly higher ever use of withdrawal in rural areas, among women there is little difference between urban and rural areas of ever use of specific methods. 6 Among men, the same four modern methods were most frequently used and in the same order; however, a much higher proportion of men, almost three-fourths, report that they have used condoms and only 36 percent and 10 percent, respectively, report that their partners ever used the pill and the injectables. A higher proportion of males (34 percent) report the use of withdrawal. The reasons for these differences may, in part, be that women who have ever used the condom with men may consider the man and not the woman to have ever "used" this male-oriented method, while men may have the same perception of the pill and the injectable when these methods are used by their female partner. In addition, many men may not even be aware that their female partners have ever used these female-oriented methods. However, the question asked was "Have you or your partner(s) ever used (method)?". As is the case for women, among men, except for the higher use of withdrawal in urban areas, there is little difference in ever use of specific methods. In 1989, the pill was the most prevalent method ever used by women, with the condom in second position. In the four-year period, there was a significant increase in ever use of condoms (34 to 52 percent). This difference is, no doubt, due in part to the fear of the transmission of sexually transmitted diseases (STDs), including AIDS, having increased since 1989. There was almost no urban-rural difference in ever use of specific methods in 1989. All respondents who had ever used contraception were asked the following question, "How old were you when you/your partner first used contraception?" The mean age at which women and men first used contraception is shown in Table 3.1.3 for a variety of social and demographic factors, and is compared with the 1989 CPS for women. Overall, mean age at first use for women was just under 20 years in both years and, except for an expected increase as current age rose and the number of live births of respondents increased, very few group differences were found. There was a slight drop in mean age at first use as the current relationship status is less stable, but, as will be explained later, this is also related to age. There was also a slight drop in mean age at first use as the frequency of church attendance decreased. On the other hand, there was no significant difference in age at first use in urban and rural areas or for the education or socio-economic groups. These data are virtually unchanged since 1989. Nonetheless, the increase in mean age at first contraceptive use among ever users as current age increases, suggests that the age at first contraceptive use has declined in Jamaica over the past 20 years. Age at first use was 21-25 years for both women and men over age 30, whereas under the age of 30 the mean age at first use was between 16 and 20 years. To confirm this hypothesis, in addition to the analysis of the mean age at first use of contraception in Table 3.1.3, further analysis of the age at first use of men and women by their current age was examined to determine the percentage who began use under the age of 20. (Since all respondents under the age of 20 who have ever used contraception must, of course, have begun use at an earlier age than 20 years, their relatively young age at first use as shown in Table 3.1.3 cannot be indicative of this trend). The results, which are not in a formal table, are shown below: 7 For women, it is obvious that the percentage who began contraceptive use under age 20 is inversely related to current age. The increase in the percentage using under age 20 for men is only true for those less than 35 years of age. While not shown, one-half (49 %) of women who had ever used contraception reported that they or their partner first used contraception before they had children, 86 percent of men reported that they or their partner used contraception before they fathered a child. Another 32 percent of women began using contraception after one child. 8 3.2 - CURRENT USE OF CONTRACEPTIVES Each respondent who reported they are currently using contraception was asked the following question: "Which contraceptive method are you or your partner currently using?" Respondents were also asked whether they or their partner simultaneously used another method as a secondary method. The tables that immediately follow present only primary method use, as has been done in previous surveys, The data on secondary method use will be presented later in this section, as will results on the percentage of respondents with more than one partner and contraceptive use by men with their other partners. These topics are new to the CPS and had not been asked in previous surveys. Tables 3.2.1 and 3.2.2 present contraceptive use by relationship status for all women and men, respectively; that is, women and men who are in union and those who are not in union. Beginning with Table 3.2.3 the data presented in the remainder of this section are restricted to women and men currently in union only. In the Jamaican context, "in union" has been defined as being married, living in a common law or consensual union or having a visiting relationship. Those persons whose partner is a boyfriend or girlfriend or who have no current partner are considered to be not in union. As was shown in Volume II, relationship status is, to a great extent, related to age, as younger men and women tend to be in a visiting relationships, and as they become older enter into a common law union and then later into marriage. Therefore, many of the data on current contraceptive use which show differences by relationship status, may also be influenced by age and other age-related variables, such as the number of live births. More detailed analysis of respondents who are not in union, who are mostly young adults, is included in Volume IV of this Report, entitled "Sexual Behaviour and Contraceptive Use Among Young Adults". Results in Table 3.2.1 (upper panel) show that 48.3 percent of all women are currently using a contraceptive method. This is compared to 43 percent of this same group of women in 1989 (p<0.05). The major method currently being used by all women is the pill (16 percent of women), followed by the condom (14 percent) and tubal ligation (10 percent). The increase in total use is due to the increase in condom use which doubled in the four- year period (from 7 to 14 percent); (p<0.05). Use of any method is highest among married women (66 percent), followed by about 60 percent of women in a common law union, in a visiting relationship or those who have a boyfriend with whom they have sexual relations. Few other women use contraception: only 3 percent of those who have a boyfriend with whom they do not have sexual relations and only 10 percent of those who do not currently have a steady partner are using a method. The choice of specific method used, or the method-mix, varies by relationship status. Among married women, the most prevalent method is female sterilization (tubal ligation), which is used by almost half of married women using any method. However, as stated previously, this is in part due to age differences; married women tend to be older and are more likely to have reached their desired family size, which in turn results in a preference for sterilization, a permanent contraceptive method. Women in a common law union, who 9 as a group are younger, show a greater preference for the pill. Among those with a visiting partner or a boyfriend, who tend to be in the youngest age groups, the condom is used to a much greater extent. The method-mix pattern was similar in 1989, except that condom use was then much lower in all relationship groups (lower panel of Table 3.2.1). Table 3.2.2 shows the same data for men. A greater percentage of men than women of any relationship status, almost 56 percent, are currently using a contraceptive method. The major method men are currently using is the condom (30 percent of men), followed by the pill (16 percent) and tubal ligation (5 percent). The large differences between male and female reporting of current use of the condom and tubal ligation use is partially explained by differences in perception of use of these methods. As mentioned in the previous section on ever use, men may be reporting use of the condom with women who, from the female point of view, do not consider themselves to be "using" this male-oriented method, while men may not always be aware that their partners are using female-oriented methods. In addition, males may be reporting use of condoms with secondary partners when no method is used with the primary partner. Unlike women, the use of any method is lower among men in a marital or common law union compared to men in a visiting or "girlfriend with sex" relationship. The primary reason for this difference is the high proportion of men in the latter two relationship categories who use condoms. As is the case for women, men in a marriage or common law relationship are older and in more stable relationships where they presumably feel they have less to fear from STD transmission, and so rely less on condoms. Among married men, the method with the highest prevalence is tubal ligation, which is reported by 22 percent. Men in a common law union, who as a group are younger, show an equal preference for both the pill and the condom. As mentioned above, beginning with Table 3.2.3, the data presented in this section is restricted to include only women and men who are currently in union. Usage rates and method-mix are examined for 1983, 1989 and 1993, comparing the results of the last three contraceptive prevalence surveys. Contraceptive use increased moderately between 1983 and 1989 by rising from 51 percent to 56 percent of women in union, an increase of 8 percent, an average of 0.8 percentage points per year; however, use increased at a greater rate between 1989 and 1993 (56 percent to 62 percent), an increase of 12 percent and 1.5 percentage points per year. The method-mix among women did not change during the 6 year period between 1983 and 1989. During that period, the most prevalent method used in Jamaica was the pill, followed by female sterilization, the condom and injectables. Change in condom use was relatively minor during the 6 years, increasing from 7.6 percent in 1983 to 9.1 percent in 1989, an increase of only 20 percent. However, the rise in use of condoms between 1989 and 1993 (9.1 percent to 16.9 percent) was a much more dramatic increase of 86 percent, accounting for most of the increase in overall contraceptive use in this latter period. This increase also changed the method-mix, as the condom became the second most prevalent method used by women in union. As mentioned above, the large increase in condom use is, no doubt, due in part to the increased fear since 1989 of the transmission of STDs, 10 including AIDS. Other than those already mentioned, the use of other methods, most importantly the IUD, is minimal in Jamaica. The method-mix among men in union in Jamaica differs from that of women. The condom is the most prevalent method used by men, as one-third of men report that they use the condom as their primary method, about twice the percentage of women who report condom use. Pill use is about the same, with lower prevalence reported for female sterilization and injectables, both of which are methods that do not require daily action. There may be several reasons, some mentioned previously, for the different method-specific prevalence rates reported for men and women. 1. The age group (15-54 and 15-44) and relationship status distributions (see Vol. I) are different. 2. Comparing male and female respondents in the same age group, it can be assumed that the partners of male respondents are younger, on average, than the female respondents. 3. In spite of the question on contraceptive use including the partner, some females may not be reporting male oriented methods such as the condom (although there does not seem to be any differential in the reporting of withdrawal). 4. Males may not know that their partner is using injectables or has had a tubal ligation. Among men in union, the second most prevalent method is the pill, as 21 percent of men report that their female partner use the pill, virtually identical with the percentage of women who report pill use. Fewer men than women report using female sterilization and the injection, the methods in third and fourth positions, respectively, among men. The next table, Table 3.2.4, compares women in union aged 15-44 years who are currently a using contraceptive method, between 1989 and 1993, by residence and selected characteristics. The 1993 CPS found that contraceptive use among women does not differ significantly between urban and rural areas, though use is slightly higher in all sub-groups in urban areas. This is the opposite of 1989 when the CPS had found that use in rural areas of Jamaica was slightly higher than use in urban areas (57 percent as against 53 percent) although the difference was not statistically significant. Between 1989 and 1993, the increase in urban areas was significantly higher than in rural areas. Contraceptive use among women in 1993 increased with age, the number of live births, education attained, socio-economic grouping and church attendance. It is higher among married women than among women in common law and visiting relationships in both urban and rural areas. In the urban areas, use reaches at least 70 percent for those with three or more children, for those with a secondary education of 5-8 years and post secondary education, and those who are in the highest socio-economic category. Contraceptive use 11 patterns according to these selected characteristics were similar in 1989. Among men, as was the case among women, the 1993 CPS also found that contraceptive use did not differ greatly between urban and rural areas (Table 3.2.5). However, unlike women, use among men decreased with age and the number of live births. As will be seen in a later table, male condom use is relatively high in all age groups compared to women, but is particularly high in the younger age groups. This explains, in part, why overall use by younger men is higher than younger women, but over the age of 35 is similar for both genders. Overall use among women increases as the level of education attained rises (Table 3.2.6). Use increases with education to a much greater extent in urban compared to rural areas, since about 60 percent of both urban and rural residents with less than 5 years of secondary education are using a method, while 70 percent of urban residents with more than 5 years of a secondary education are using contraception, compared to only 64 percent of rural residents. Overall use also rises with education in all age groups, although over the age of 30, it drops among women who have some post-secondary education. Use by education rises most sharply among women with fewer than three live births. Among women with 3 or more live births use is uniformly high. Similar trends are seen in the 1989, but contraceptive use has increased in each educational category. Among men the overall level of contraceptive use is higher among those who have at least five years of secondary school (Table 3.2.7). These trends are the same in almost all socio- economic groups. Looking now at specific method use, in general, as age and the number of live births increase, women tend to use more effective methods (Table 3.2.8). The most prevalent method used by women under the age of 20 is the condom, which is used by well over half of all female users in this age group (upper panel of Table 3.2.8). Between ages 20 and 34, the pill is the most prevalent method used, followed by the condom and injections. After age 35, female sterilization is the most prevalent method used, and by age 40 three-fourths of women in union using any method are sterilized. The use of injectables follows the same pattern as the pill; that is, use is highest, by about 8 percent of women, between the ages 20 and 34. A similar pattern was seen in 1989, although the level of condom use was about half that of 1993 (lower panel of Table 3.2.8). Another difference in 1989 was that injectable use was slightly higher in all age groups. The same pattern is seen in Table 3.2.9 which shows women's contraceptive use by mean age in both 1993 and 1989. In 1993 women who use condoms are on average at least two years younger than women who use the pill and injectables, while women who are sterilized are almost nine years older than pill and injectable users. The pattern was similar in 1989. Among men, the patterns of contraceptive use by age group are similar to those of women, except for a greater use of condoms by all age groups and a decrease in contraceptive use with age, especially after the age of 50 (Table 3.2.10). Unlike women, overall contraceptive use by men decreases after age 34. This is because condom use and therefore, overall use, 12 is very high among younger men. As men get older, condom use drops from 57 percent of men under 20 to less than 30 percent of men over age 30 and only 13 percent of men over age 50. At the same time, there is no corresponding increase in the use of other methods with increased age to compensate for the fall in condom use. Although sterilization (as well as pill and injection) use by the female partners of men in union follow the same pattern as reported by women, since their female partners are younger on average than female respondents, the level of female sterilization use reported by older men is lower than that of women in the same age groups. This could also be due to some older men being unaware that their female partners are sterilized. Nonetheless, although men over 40 report a higher level of sterilization use than condom use, in no age group do men report that condom use is lower than pill use. Therefore, in general, as age increases, men do not tend to use more effective methods to the same degree as women. Contraceptive use increases as the number of live births to women increases to three or more (upper panel of Table 3.2.11). Use reaches over 71 percent for women with three children, and is 60 percent or less for women with less than three children. The condom is the primary method used by women with no children. For women with 1-2 children, the pill is the most prevalent method used, followed by the condom. As expected, female sterilization increases with the number of living children, as it becomes a major method for women with 3 children and is by far the most prevalent method for women with 4 or more children. The data were similar in 1989, except the level of condom use was lower (lower panel of Table 3.2.11). Since, as mentioned earlier, the number of live births to women is related to age, the patterns of contraceptive use according to this variable are almost the same as for age; that is, as the number of live births increases, women tend to use more effective methods. It is important to note that, due to increased condom use, a significantly greater proportion of women in union with no children or one child are contracepting in 1983 compared with 1989. The pattern of contraceptive use by men according to the number of live births is different than that of women (Table 3.2.12). No significant difference is seen in overall prevalence by number of live births. Condom use falls as the number of live births increases, from 49 percent of men with no live births to 19 percent of men with 4 or more live births. Pill use rises and then falls, while tubal ligation use increases from 1 percent of men with no live births to 22 percent of men with 4 or more live births. As seen earlier in Table 3.2.4, the use of contraception among women is positively associated with education (59 percent for those with a primary education or less versus 67 percent for those with a post secondary education). In addition, the upper panel of Table 3.2.13 shows that the method-mix changes as education increases. Female sterilization is used to a much greater extent by those with primary education (19 percent) than those with higher levels of education. As education increases, condom use increases. The pattern was similar in 1989, except the increases in condom use for respondents with higher education was not nearly as striking, as overall condom use in 1989 was much lower. The pattern of use of individual contraceptive methods according to educational attainment 13 is different for men (Table 3.2.14). Compared with women, condom use is higher in each education group, but the prevalence does not double between the lowest and highest groups as reported by women. Female sterilization among partners of men shows a U-shaped distribution, with highest prevalence among men with primary and post-secondary education. Unfortunately, the survey did not obtain data on the educational attainment of the female partner who actually had the tubal ligation. This is an important omission and will be included in future male surveys. Differences in contraceptive use by frequency of church attendance are not great, although those women who never attend church or who report no religion have a slightly lower level of use, but is not significantly different (Table 3.2.15). However, the method-mix does differ somewhat. As frequency of church attendance decreases, the use of the pill increases from 17 percent of those who attend church at least weekly to 28 percent of those who never attend church, while the use of sterilization decreased from 20 percent to 8 percent in the same groups. Among men there was a similar decrease in the use of sterilization by their female partners, but pill use showed no particular pattern. Fifty percent of women in union stated that they do not want any more children, while 40 percent do want additional children and 10 percent are not sure. The use of any contraceptive method is virtually the same for women who want more children (65 percent) compared to women who do not want more children (66 percent) (upper panel of Table 3.2.16). However, the method-mix of these two groups differs greatly. Women who want more children tend to use either reversible methods such as the pill (27 percent) and condom (26 percent) and, of course, do not report female sterilization at all. As might be expected, the method used by women who want no more children is much more likely to be sterilization, an irreversible, permanent method. As a result, in this group the most prevalent method is female sterilization (27 percent), while use of the pill (17 percent) and, even more so, the condom (11 percent) is much lower. Although not shown in this table, women who want no more children are much more likely to be older and, therefore, their pattern of use is similar to that of women in the oldest age groups; that is, higher use of sterilization and less use of pill and condoms. Only thirty percent of men in union stated that they do not want any more children, while 56 percent do want additional children and 14 percent are not sure. Although many more men than women are using condoms, as is the case for women, a greater percentage of men who desire more children are using condoms than men who do not want more children (lower panel of Table 3.2.16). More than one-fourth (27 %) of men who desire no more children report their partners are sterilized. To summarize the above findings, overall contraceptive use is high for all socio- demographic groups and does not vary greatly by age group. However, the choice of method does vary, with women and to a lesser extent, men, moving from the condom to the pill and then to female sterilization as they get older. The next topic covered in this section is use of a second contraceptive method with their primary partner by men and women in union. A direct question on use of a second method 14 was asked in the 1993 Survey. This had not been included in previous surveys. Table 3.2.17 presents a percent distribution of the second method used by users of each first method for which there are 25 or more users. When analyzing the data for primary method use, in those instances where a respondent reported using a second method that was more effective than the first method reported, the data were then modified to make the second method the first and vice versa.3 The results show that only six percent of female users report using a second method (upper panel of Table 3.2.17). Condoms are the most prevalent second method among women. Eight percent of pill users, 5 percent of injectable users and 1 percent of sterilization users have partners who use condoms as a second method (Table 3.2.17). Almost 8 percent of female condom users also used withdrawal as a second method. Looking now at men, the bottom panel of Table 3.2.17 shows that, compared to women, a greater percentage of men, almost 20 percent, were concurrently using a second method, mostly condoms. Relatively large percentages of men whose partners are pill or injection users (37 percent and 20 percent), respectively) use condoms as a second method. Also, three percent of men whose partners are sterilized use condoms as a second method. Almost 10 percent of male condom users used withdrawal as a second method and almost 10 percent of withdrawal users stated that they used natural family planning (rhythm, billings, etc.) as a second method. (Whether or not they used withdrawal during their female partner's fertile period is open to speculation.) Another new topic added to the 1993 survey is contraceptive use by men with a second sexual partner. This data was collected for all respondents, not only those in union. Since so few women, (less than 2 percent) reported a second partner in the last month, results are shown only for men. Table 3.2.18 show that 21 percent of sexually active men report they have a second sexual partner. The percentage is highest among men with no current steady partner (39 percent) and those in a visiting relationship (31 percent). Having a second sexual partner declines with increasing age. Almost three-fourths of those sexually active men with more than one second sexual partner used a contraceptive method with their next-to-last sexual partner (Table 3.2.19). This is higher than the percentage of all men (56 percent) who use contraception with their primary or only sexual partner (as shown in Table 3.2.2). Fifty-eight percent of men with more than one partner used the condom with their next-to-last partner, which means more than two-thirds of men who report use of a method with these partners used the condom. The pill is in second position. Very few men or their next-to-last partner used other methods. Overall use (and condom use) with next-to-last partners decreases somewhat as unions with the last partner become more unstable. There was a slight drop in the use of any method with a next-to-last partner with increased age, reflecting a similar drop in overall male use with their primary or only partners (Table 3.2.20). Looking at specific methods, there is also a drop in condom use and an increase in pill use with greater age, which is also similar to use with primary partners, but differences are not statistically significant. 15 Finally, Table 3.2.21 shows that almost 20 percent of men were concurrently using a second method, mostly condoms, with their second partner. Most of this is due to men whose second partners are pill users, as 61 percent of this group concurrently use condoms as a second method. This is a much higher percentage than the 37 percent of men whose primary partners are pill users who concurrently use condoms as a second method (see lower panel of Table 3.2.17) and is, no doubt, due in part to fear of STD transmission. 3.3 - CONTINUATION AND NON-USE OF CONTRACEPTION The 1993 JCPS questionnaire included a monthly contraception/ pregnancy calendar covering the period from January, 1988 to the month of interview. The calendar included a month-by-month report of pregnancy status, whether and what type of contraception was being used and whether a respondent discontinued contraceptive use. The information collected in the calendar permits the calculation of probabilities of discontinuation for widely used contraceptive methods. The discontinuation rates were calculated using life table techniques.4 Discontinuation rates for the major contraceptive methods were quite high. For each of the three major reversible methods, approximately one-half of women had discontinued use of the method for any reason within 12 months of starting it (Table 3.3.1): oral contraceptives (46%), injectables (47%), and condoms (55%). Discontinuation rates after 36 months for all three methods were around 80%. These rates, although seemingly high, are not unusually high compared to rates found in surveys in other developing countries.5 Twelve month discontinuation rates for oral contraceptives were significantly higher in urban areas than in rural areas while, for injectables, discontinuation was higher in rural areas. For each of the three methods examined, married couples were consistently found to have higher rates of discontinuation than those in common law or visiting unions, although the differences were generally not statistically significant. Further analysis needs to be done to see if the patterns of contraceptive starting and stopping may be contributing to the high levels of unintended pregnancy found, as well as to the failure of fertility rates to decline. For instance, if women/couples change methods frequently, there may often be periods of sexual activity when women are not protected from pregnancy. This could conceivably result in higher rates of pregnancy than would be anticipated given reported levels of contraceptive use. The reasons why women and men say they are not currently using contraception are examined in the next series of tables. Eighty-one percent of women gave reasons related to pregnancy, subfecundity or sexual activity for non-use (Table 3.3.2). Most said they were not sexually active, 12 percent reported they were currently pregnant, a further 8 percent reported they were sub-fecund and 6 percent indicated a desire to get pregnant. The remaining 19 percent of the women gave other reasons which place them at risk of an unintended pregnancy. These data are similar to the corresponding data from the 1989 CPS. A much lower percent of men (6 percent) gave reasons not related to pregnancy, subfecundity or sexual activity. Most of the men said that they were not sexually active. 16 There is an unexplained discrepancy between the percentage of women reporting current pregnancy and men reporting that their partner is currently pregnant. Reasons for non-use are presented by several social and demographic factors in the next tables (Tables 3.3.3 - 3.3.10) and the following points can be made: (1) Reasons for non-use by women vary according to relationship status (Tables 3.3.3). While the major reasons for non-use by women who are in a marital or consensual union were current pregnancy or sub-fecundity, the primary reason for women in a less stable or in no relationship was absence of sexual activity. For men not in a union, all reported that they were not sexually active (Table 3.3.4). (2) Reasons for non-use did not vary by residence; in both urban and rural areas in 1989 and 1993 about 80 percent of the women gave reasons related to pregnancy, infertility and sexual activity (Table 3.3.5). Except for a slightly higher percentage of rural compared to urban women in 1989 who reported they were not using because they were post-partum or breastfeeding, the data were similar in 1989. The same was true of men: about 95 percent of men reported reasons related to pregnancy, infertility and sexual activity in both urban and rural areas (Table 3.3.6). (3) Reasons for non-use by last contraceptive method used show that those women who have never used a method are most likely (70 percent) to report they are not using because they are not sexually active (Table 3.3.7). As was seen earlier in Table 3.1.1, never users are most likely to be in the youngest age group, who are more likely not to be currently sexually active. Those women who last used a hormonal method, the pill or injection, were more likely to give other reasons, particularly those reasons related to side effects and health concerns, as a reason for not currently using a contraceptive method. At the same time, men whose partners last used the pill were less likely to report they were not sexually active and more likely to report they "did not like.[contraception]" as a reason for non-use (Table 3.3.8). (4) Reasons for non-use change according to age (Table 3.3.9). At ages less than 25, women are most likely to say they are currently pregnant or not sexually active. In the middle age groups, 25-34, a higher percentage of women state that they desire pregnancy as a reason for non-use. In the older age groups, 30 and over, a higher percentage of women say they are sub-fecund. The same pattern was found in 1989. A somewhat similar pattern was found among men (Table 3.3.11): the proportion who reported they are not sexually active as a reason decreased with age, while the proportion who reported their partner was sub-fecund increased. Like women, in the middle years, 30-44, men were more likely to report a desire for pregnancy as a reason for non-use. All non-users of contraception were asked whether in the future they would like to use a method to prevent pregnancy. Sixty-nine percent of women answered in the affirmative (Table 3.3.11). Overall, more than one-third of women who wanted to use a method stated they wanted to use the pill, followed by the condom, injectables and tubal ligation. Over half (58 %) of married women report they want to use a method, with tubal ligation and 17 the pill the methods most often mentioned. Desire to use sterilization is highest among married women and then decreases as relationships become less stable. Table 3.3.12 reports the corresponding data for men. Only 43 percent of men not currently using report they would like to use contraception at some time and, unlike women, this percentage decreases as relationships become less stable. Few of those with no sexual relationship stated that they would like to use a method in the future. 3.4 - STERILIZATION - USE AND DEMAND The profiles of in union women who have and have not been sterilized are compared in Table 3.4.1. In this table, it may be observed that women who have been sterilized tend to be 9 years older, on average, than the non-sterilized (mean age of 36 years compared with 27 years), to have over two children more, on average, than the non-sterilized (mean of 4.3 compared with 1.9), to be in a more stable relationship, to be less educated (48 percent compared with 28 percent with primary education or less) and to attend church more frequently. The above data on mean number of live births indicate that, in Jamaica, those women who become sterilized tend to be self-selected for their higher parity. The lower educational attainment of sterilized women is due in part to high parity being negatively correlated with education. These data have not changed significantly since 1989, except that sterilized women are better educated in 1993, as are all women. Trends are similar for men in union, except that the men whose partner has been sterilized are six years older on the average and those whose partners are not sterilized are four years older on the average than women who have been surgically sterilized (Table 3.4.2). However, it must be noted that men in the sample are up to 54 years of age. There is an 11 year difference in age between men whose partners have had surgical contraception and those whose partners have not had this procedure. Table 3.4.3 examines, for those women in union who have been sterilized, when during their reproductive life the event took place. Close to 70 percent of women were sterilized between ages 25 and 34, with a mean age of 30. Sixty-four percent of sterilized women already had 4 or more live births, with a mean of 4.3. Also, more than one-third of the sterilizations occurred since 1990. The data for 1989 show that since that time the mean number of live births at sterilization has fallen slightly (by 8.5 percent.), although there was essentially no change in the mean age. The extent to which in union women who are sterilized have never used another method is examined next (Table 3.4.4). The results show that only 14 percent of these women have never used any other method prior to sterilization. The average number of children ever born to sterilized and non-sterilized women are compared by age group in Table 3.4.5. In each age group, the sterilized women have at 18 least one child on average more than the non-sterilized, with the difference narrowing as age increases. This, again, is an indication that those women who are sterilized in Jamaica tend to be self-selected for their higher fertility. The results in Table 3.4.6 show the extent to which women and men and/or their partners received counselling prior to the sterilization operation. Only forty-five percent of women and 63 percent of men said that they or their partner received counselling. The majority of those counselled were told the operation means no more children, how it is performed and that it does not affect sex life. However, more than half did not indicate that they were told that a successful operation means no more children. This is a serious quality of care problem. Fewer respondents were counselled on other topics. Also, less than one- third were counselled on what to do in the event of post-operative complications. Thirteen percent of sterilized women stated that they were not satisfied with having had the operation (Table 3.4.7). Dissatisfaction was highest for women who were less than 30 years at the time of sterilization, women not in a marital union (who tend to be younger women) and those who were not counselled prior to the operation. Half of the women who expressed dissatisfaction with having been sterilized stated the reason was either that they had side effects or complications related to the operation. Relatively few, less than 10 percent, expressed regret at not being able to have more children (Table 3.4.8). Nine percent of men expressed dissatisfaction that their partners had been sterilized (Table 3.4.9). No age difference is seen as was reported by women. A greater percentage of urban men, less educated men and those who were not counselled prior to the operation were dissatisfied. However, due to small sample size, these differences are not statistically significant. Results in Table 3.4.10 focus on the potential demand for sterilization among women who are fecund and men whose partners are fecund (i.e., capable of getting pregnant) and who do not want any more children. About one-third of women (35 percent) state that they are interested in having the operation. This interest is higher for women who are in union, who have 4 or more children, are 30-34 years of age, and/or not using contraception. A much lower percentage of men (10 percent) expressed interest in their partner seeking sterilization to limit childbearing. With the small numbers in the subgroups shown, there are no statistically significant differences. Finally, those women and men who did not want more children and were interested in sterilization and who were not sterilized, were asked the reason why they had not sought out sterilization (Table 3.4.11). Eighteen percent said they were afraid of the operation or feared side effects. Another 17 percent of women said they lacked information on sterilization, 11 percent said they were too young and 10 percent reported they could possibly want more children in the future if their personal situation changed. Certainly, the 35 percent of these women in the first two categories, as well as a further 17 percent who are "thinking about it", "planning to do so soon" and who are currently pregnant could presumably be the target of IEC activities to inform them of the benefits and safety of female sterilization. There was little difference in these data according to the residence 19 of female respondents, except twice as many rural women compared to urban women thought they might want more children in the future. A much higher proportion of men than women (32 percent) were not sterilized themselves or their partners were not sterilized because they had no information on the subject (right- hand column of Table 3.4.11). Also, unlike women, while no men reported they or their partners had not been sterilized because they feared the operation itself, presumably because they had in mind that their female partner would undergo the procedure, 13 percent of men, compared to only 4 percent of women, said they feared the side effects of the operation. Table 3.4.12 presents the same data on reasons for non-sterilization of women by educational attainment. There are no significant differences by education, given the number of cases available. 3.5 - WOMEN AND MEN IN NEED OF FAMILY PLANNING SERVICES The survey data indicate that certain segments of the population have greater need of family planning services than others. A woman was characterized as "in need of services" (or "at risk of an unplanned pregnancy") if she was sexually active, not currently pregnant, stated that she did not desire to become pregnant, and she was not using any method of contraception for reasons not related to subfecundity. Thus, the women defined in this study as "in need of services" are non-contracepting, fecund, sexually active women (regardless of marital status), who were not currently pregnant and did not desire to become pregnant at the time of the interview. Men were similarly defined as being in need of family planning services, using the fecundity and pregnancy status of their female partners. According to this definition, 14 percent of the women had unmet need for contraception, compared to a slightly higher proportion, 16 percent, in 1989 (Table 3.5.1). Results in Tables 3.5.1 and 3.5.2 show the level of unmet need varied by the characteristics included in the study. The following summary points can be made: (1) Married women had lower unmet need than women in less stable unions (common law and visiting partner) and those not in union. (2) One of six adolescents are at risk of an unplanned pregnancy. (3) Unmet need rose as frequency of church attendance fell. To summarize, the need for family planning services among women is approximately 14 percent for all sub-groups of the characteristics studied, except for married women who use contraception to a greater extent, women who never attend religious services and women 40-44, whose level of subfecundity is higher and whose level of need is lower. 20 Except for married women being a smaller proportion of women in need than they are of all women, the characteristics of women in need of family planning services are not different from the characteristics of all women (Table 3.5.2). This is because married women in Jamaica tend to be older and are more likely to have reached their desired family size. However, family planners in Jamaica should take into account the fact that two-thirds of women in the country, including those in need of family planning services, live in rural areas. A greater proportion of men than women, 20 percent, are in need of family planning services (Table 3.5.3). Married men had the lowest level of unmet need 7 percent, while men in less stable unions (common law and visiting partner) had much higher levels of unmet need, 22 percent and 16 percent, respectively. Those men without a current partner had a very high level of unmet need for family planning services, 38 percent. Men who are under the age of 25 have the greatest need, as do men with no live births and/or men who did not complete the second half of secondary school. Not shown in a table is that almost half, 44 percent, of men in this education category are under the age of 20. Therefore, their high level of need is more a function of their young age than their level of education and, as stated above, youngest men have the greatest need for family planning services. As is the case for women, most men in need, live in rural areas, have no current steady partner, are young adults, have never had a child and rarely attend church services (Table 3.5.4). Unlike women, they also tend to be less educated. 21 CHAPTER IV AVAILABILITY AND COST OF CONTRACEPTIVE SERVICES Chapter IV discusses availability and cost of contraceptive services in three sections. Section 4.1 covers sources of contraception and examines distance from source and Section 4.2 addresses the willingness of respondents to pay for their contraceptive and the amount they are prepared to pay. 4.1 - SOURCE OF CONTRACEPTION The source of the four major methods for women varies according to the method (Table 4.1.1). Women largely obtained their pills and condoms in pharmacies and government health centres, with urban users patronizing pharmacies to a greater extent than rural users. Twelve percent of rural condom users get their method in shops and markets. Seven percent of women do not know the source of their condoms, presumably because they are obtained by their male partner. Since they require a medical intervention, almost all injections and female sterilizations were obtained from government health centres and government hospitals, respectively, and to an even greater extent in rural areas than in urban areas. The major difference in the sources of contraception since 1989 is that, currently, lower percentages of pills and, especially, condoms are obtained in government health centres, signalling a shift to the private sector as a source for these methods (Table 4.1.2). The source of injections and female sterilization for women has been virtually unchanged since 1989. For men, the source of the four major methods is similar to that of women (Table 4.1.3). The main difference is that men obtain condoms from both pharmacies and government health centres to a lesser extent than women, while the greatest percentage of men, 38 percent, get their condoms from shops and markets. Also, 11 percent of men reported that their female partners obtained their sterilization in private hospitals, especially in urban areas (21 %), compared to only 4 percent of women reporting this source. About half of female pill and injection users and more than 60 percent of condom users are within 2 miles of their contraceptive source (Table 4.1.4). Condom users are slightly closer to their source since a greater percentage of these are obtained in pharmacies, shops and markets which, presumably, are more numerous and, therefore, closer than public sector sources. For the same reason, in general, urban users are closer to their source than rural users, since, as seen above, they use private sector sources to a greater extent than rural users. 22 Men are even closer than women to their contraceptive source. About 60 percent of males whose partners are pill and injection users and almost three-fourths of condom users are within 2 miles of their source, with urban users closer than rural users (Table 4.1.5). 4.2 - WILLINGNESS TO PAY FOR CONTRACEPTIVES Section 4.2 looks at the history of payment of respondents for the contraceptives which they have been using, their willingness to pay for those methods for which they are not now paying, and the amount they are prepared to pay. Coverage is limited to those persons who are using the particular method. Table 4.2.1 (upper panel) shows that almost all women, regardless of the modern method they use, either already pay or are prepared to pay for their contraceptive method. The middle panel of this table presents data on whether those who already pay or who are willing to pay for their method can state the maximum amount they are prepared to pay. Although most users of any of the three methods could specify this amount, a greater percentage of condom users, almost one-third, compared to 16-26 percent of pill and injection users, reported they would pay any amount or did not know the amount they would pay. This could be due to condoms being used as a method for disease prevention as well as for contraception, but since they cost little, there may be an expectation that "any amount" would not be expensive. The lower panel shows that the median amounts women were prepared to pay are about $J10.00 (US$ 0.40) for a monthly cycle of pills, between J$6.00 and J$8.00 (US$ 0.24-US$ 0.32) per condom and J$ 50.00 (US$ 2.00) for a 3-month injection. The monetary amounts are similar for those who already pay and those who are willing to pay. The data on willingness to pay for contraception were similar for men (Table 4.2.2). Like women, almost all men either already pay or are prepared to pay for their contraceptive method. A similar percentage of men compared to women could specify the amount they were willing to pay for condoms or who would pay any amount. However, for pills and injectables, since women not men buy these methods, a lower percentage of men compared to women, only about half, could specify the amount they were willing to pay for them. The median amounts men were prepared to pay for their methods were essentially the same as those reported by women. 23 CHAPTER V FERTILITY 5.1 - GENERAL FACTORS INFLUENCING FERTILITY All female respondents were asked: "How old were you when your first period started (first started menstruation?)". The results in Table 5.1.1 show the mean age at the first menstrual period (menarche) is just under 14 years. There is virtually no difference between urban and rural areas. Due to improvements in nutrition and health in general, the age at menarche has been declining in many countries, including Jamaica. In the past 25 years the mean age at menarche in Jamaica has fallen, as women currently aged 15-19 had their first period at 13.2 years, compared to 14.4 years for women currently aged 40-44 years. The greatest decrease has been experienced by women in the youngest age group whose mean age at menarche of women is more than eight months (0.7 year) less than women currently aged 20-24 or 25-29. Mean age at menarche also declines as educational levels increase, possibly due to women in higher education categories experiencing higher levels of health and nutrition, but also influenced by women in higher educational categories being younger than less educated women. The fact that there are virtually no difference by socio-economic index supports the latter explanation as the most likely case. In Jamaica, approximately one-third of all women aged 15-44 are childless (Table 5.1.2). As expected, the percentage of women who are childless generally decreases with age. Four-fifths (80 percent) of women under the age of 20 are childless and nearly two-fifths (39 percent) of those in the age group 20-24 are childless. Seven percent of women aged thirty-five and older are childless. There is little difference in childlessness according to residence, but less educated women are less likely to be childless than those in higher educational categories. There is a similar difference according to socio-economic index. 5.2 - PLANNING STATUS OF LAST PREGNANCY An assessment of the success women and men have in having the number of children when they want to have them may be made through consideration of the planning status of their children. For women, questions on planning status referred to their last pregnancy; for men, they related to their first child or their last child. All female respondents were asked two questions concerning the planning status of their last pregnancy. "When you became pregnant, did you want to become pregnant?" If not, "Was it that you wanted no more children, or that you just wanted to wait longer before another pregnancy?" On the basis 24 classified as either "planned", "mistimed", "unwanted", "unplanned, unknown status" (not known whether mistimed or unwanted) or unknown. Planned births were defined as those that were wanted; mistimed were classified as those that were wanted, but at some time in the future; and unwanted births were those not wanted, even in a future time. Using this scheme, the mistimed, unwanted and unplanned, unknown status births can be combined as an estimate of unplanned births. Male respondents were asked: "Did you plan to have your last (only) child?" and if they had more than one child, in a separate question, "Did you plan to have your first child?" Using these questions, births to the female partners of men were classified as either "planned" or "unplanned". Tables 5.2.1 to 5.2.3 use the above definitions to present data on the planning status of pregnancies of women during the 5 years prior to the survey and first births and last births to partners of men regardless of when they occurred. Almost half of pregnancies of women in the past 5 years (48 percent) were reported to be mistimed and another 19 percent were unwanted (Table 5.2.1). Only 29 percent, three in 10, were planned. Although slightly higher than the 25 percent of pregnancies reported as planned in 1989, the difference is not statistically significant. Unwanted pregnancies were higher (p < 0.05) in rural than urban areas (22 percent vs. 13 percent), reflecting, in part, the higher parity of women in rural areas. Unwanted pregnancies are also positively associated with the number of children ever born (over half of births to women who had four or more children were unwanted). The great majority of pregnancies of women under 25 are mistimed. This percentage falls rapidly as age increases, while the percentage of unwanted pregnancies increases. Over the age of 40, almost 60 percent pregnancies are unwanted. Unwanted pregnancies were negatively related to education (27 percent of women with primary or less education had unwanted pregnancies) and socio-economic status. Over half (52 %) of last pregnancies of married women were planned, which is much higher than the proportion of planned pregnancies for women in less stable relationships (17-29 %). The majority of births to those in a visiting relationship or a less stable relationship were mistimed (58-66 %). With the relatively high contraceptive prevalence in Jamaica, these high proportions of mistimed and unwanted are worrisome. As seen in the previous chapter, continuation rates for all reversible methods are low and periods between method switching may contribute to unplanned pregnancies. Forty-two percent of the last births fathered by males were reported to be unplanned, a significantly lower figure (p < 0.01) than that reported by females (Table 5.2.2). As seen in the female sample, the proportion of unplanned births reported by men declines, in general, with education and socio-economic status. There is also a significant difference (p < 0.05) in unplanned births reported by men in a legal or consensual union versus those in less stable unions or not in union. 25 Less than 50 percent of the first births fathered by men were reported to be planned (44 %) by the male partner and 52 percent were unplanned (Table 5.2.3). The lower percentage of these first births that were planned, compared to last births, can be attributed to men as a group having been younger when their first child was born. Fully 73 percent of first births to 15-19 year old men were reported to be unplanned. As the age of men at the time of the first births rises, the percentage of first births that were planned rises dramatically. Also, the proportion of planned first births to men is highest for those men with the highest education status and highest socio-economic status, and for those in a legal marital union. 5.3 - CURRENT FERTILITY ESTIMATES Age-specific fertility rates (ASFR) and the total fertility rate (TFR) from the 1993 JCPS, calculated for the years 1990 to 1992, are displayed in the last column of Table 5.3.1. Fertility rates from three previous national surveys conducted in 1975-76, 1983, and 1989 are shown as well. The TFR calculated for the 1993 survey was 3.0, not a significant change from the rate of 2.9 found in 1989. Not only did the TFR remain relatively constant, none of the ASFRs exhibited any substantial change between the two surveys. This failure to see any evidence of a decline in fertility since the late 1980s comes as somewhat of a surprise in light of the considerable increase in contraceptive prevalence (CPR). This apparent levelling off of rates of childbearing comes after a period of rapid fertility reduction between the early 1970s and the late 1980s, during which the TFR fell by about one-third. Despite the apparent lack of change in fertility, the TFR for 1993 was very close to what would have been expected for a country with Jamaica's CPR, according to the regression equation used to plot contraceptive prevalence against TFR*. The TFR reported for 1989 was slightly below what would have been expected with the CPR that existed then. It appears, then, that an explanation for the 1989 fertility rate being so low may be needed, rather than an explanation for the 1993. However, there are several possible explanations for the 1993 JCPS failing to register a fertility decline in spite of increased contraceptive use. Four of these possible explanations are: 1) Fertility did, in fact, decline, but the decline was not registered in the two surveys. It is possible that there were some differences in the two samples since the 1993 survey was based on newly designed sampling frame, differential completeness/quality of reporting, or random differences between the two surveys resulting in the appearance of a lack of change. 2) The reported increase in contraceptive prevalence among women in union was not an "effective increase". Virtually all of the reported increase was due to greater condom use. It is possible that much of this use was sporadic and failed to result 26 in reduced childbearing and that the rise in contraceptive use was neutralized by a fall in the overall effectiveness of contraception. 3) Since the reported CPR is a measure that relates only to women in union, while the TFR relates to the whole population, it is possible that fertility rose among those not in union, countering a decline in fertility among those in union. 4) Proximate determinants of fertility other than contraception could be involved. For instance, a shortening of the period of postpartum abstinence, which, in fact, did occur, or a decline in the abortion rate could contribute to increases in fertility, all else being equal. (NOTE: Abortion is not legal in Jamaica). Table 5.3.2, which shows age-period fertility rates, can be used to examine recent fertility in a different way. Reading down any column gives the fertility rates for a given age group over time, based on data from reported birth histories from the 1993 JCPS. For example, the fertility rate among 15-19 year old women fell from .153 for 1973-1977 to .108 for 1988- 92. Looking at fertility change in this way reduces the chance that differences between the 1989 and 1993 samples affect the fertility comparisons. Table 5.3.2 clearly shows the well documented fertility decline before 1989 for all ages up to ages 30-34. It also indicates that there may in fact have been a decline in fertility under age 25 between 1983-87 and 1988- 92, something which did not appear when data from two separate surveys were compared in Table 5.3.1. Neither Table 5.3.1 nor 5.3.2 give any indication of a reduction in fertility among women older than ages 20-24 since the late 1980s. As with the findings in Table 5.3.1, though, there is no evidence that the TFR changed significantly between 1983-87 and 1988-92. 5.4 - BREASTFEEDING AND POSTPARTUM INSUSCEPTIBILITY Breastfeeding has two notable effects that make it important to include in surveys of reproductive health. First, breastfeeding can improve the health of infants, mainly through ensuring adequate nutrients and providing maternal antibodies to prevent disease in newborns. Second, by delaying the return of ovulation, breastfeeding increases the length of the interval between pregnancies. Among women who had a live birth in the two years preceding the date of interview, 94 percent breastfed their most recently born child (Table 5.4.1), a slight decline from the 96 percent reported in the 1989 survey. Differentials according to age and urban-rural residence in the proportion ever breastfed tended to be small. Ninety-nine percent of women with any post-secondary education breastfed their last child, a higher level than for any other subgroup examined. The likelihood of breastfeeding was also highest among those with of high or medium socioeconomic status. Somewhat surprisingly, a woman's employment status did not appear to affect whether she breastfed her child. The mean duration of breastfeeding, which was calculated by examining proportions of 27 infants currently breastfed according to their age, was 12.4 months, virtually unchanged from the 1989 survey. Differences in mean duration between most population subgroups were very small. The mean duration of exclusive breastfeeding was short for the population as a whole, 1.7 months, as well for every subgroup of the population. This indicates that even though Jamaican women typically breastfeed for about one year, they usually start giving their babies liquids other than breast milk at a very early age. This early introduction of other liquids tends to reduce the intensity of breastfeeding, thereby shortening the amenorrheic period and reducing the health benefits of breastfeeding. Table (5.4.2) shows distributions of the time, relative to the birth, at which breastfeeding Jamaican mothers first nursed their babies. Overall, almost half (46 %) first breastfed within one hour of their child's birth, another 30% began at one to six hours. Sixteen percent started nursing more than 24 hours after delivery. Women living in rural areas were reportedly much more likely to begin breastfeeding in the first hour than women in urban areas: 54% compared with 32%. The length of time it takes for a woman to again be at risk of pregnancy following the birth of a child, known as the postpartum insusceptible period, is determined primarily by the duration of postpartum amenorrhea (which itself is governed to a considerable degree by the length and intensity of breastfeeding) and the timing of the resumption of sexual intercourse. Table 5.4.3 presents the proportions of women giving birth within two years of interview who were still breastfeeding, who were still amenorrheic, and who had yet to resume sexual intercourse, according to the time since birth. Anyone who was still amenorrheic or was still sexually inactive was considered to still be in the postpartum insusceptible period. Except for breastfeeding, the proportions still in any of the categories listed declined rapidly after the first two months postpartum (Table 5.4.3). At 3-4 months only 39% were still experiencing postpartum amenorrhea and by 13-18 months this figure fell to 3%. The mean duration of amenorrhea was only 4.7 months following a live birth, with a median that was even shorter. Although 86% of women with births in the last two months had not resumed sexual intercourse, within one year few women were still sexually inactive. Because of the generally quick return of the menses and the lack of prolonged postpartum abstinence, the postpartum insusceptible period tends to be short, with a mean of 7.2 months and a median of about 5 months. The estimated mean length of the insusceptible period decreased between the 1989 and 1993 surveys from 9.0 to 7.2 months, and the proportion of women recently giving birth still insusceptible fell as well, from 37% to 29%. This change could be offsetting any possible fertility decline associated with the increased use of contraception. Table 5.4.4 displays percentages of women with births in the previous two years who were still breastfeeding, amenorrheic, sexually active, and in the postpartum insusceptible period, according to various characteristics. As one might expect the length of amenorrhea and, therefore the insusceptible period increased with age. The proportion still in the postpartum insusceptible period tended to decrease as education and socioeconomic status 28 increased. 5.5 - MATERNAL HEALTH AND CHILD CARE The importance of receiving antenatal care during pregnancy is well recognized and has been emphasized in the Government's health care programme through its effort to reduce infant mortality and to maintain or improve the health of mothers. Therefore, data on women who received antenatal care is presented to assess the degree of utilization of these services. Table 5.5.1 presents data on the percentage of pregnancies during which women received antenatal care in the 5 years preceding the survey and is compared to data from the 1989 survey. Antenatal care is almost universal, as women received care during 98 percent of all pregnancies within the past 5 years, as was the case in 1989. There was little difference according to socio-economic characteristics. About 80 percent of pregnancies were cared for in government clinics or hospitals, while the other 20 percent were cared for by private doctors or private hospitals (Table 5.5.2). As was the case for the source of contraception (see Chapter 4.1), there seems to be a movement toward utilization of private sector sources of antenatal care, since in 1989 only 11 percent of pregnancies were cared for by private doctors or private hospitals and 88 percent received their care in government clinics or hospitals. Private sector sources of antenatal care are used to a greater extent by urban women, older women, lower parity women and women who are better educated and in higher socio-economic groups. In the last five years women made at least 5 antenatal visits for more than 80 percent of their pregnancies (Table 5.5.3). The greatest number of antenatal visits were made by urban women, as more than half of pregnancies in this group resulted in 8 or more visits. Fewer numbers of antenatal visits were made for pregnancies among women who were in lower educational and socio-economic groups. This was also the case among women of higher parity, who tend to be in lower educational and socio-economic groups. IEC efforts encouraging women to go for complete antenatal care must be directed toward younger, rural women in the lower socio-economic categories. The dangers of low birth weight and fetal alcohol syndrome because of smoking and drinking alcoholic beverages during pregnancy are well known. Eleven percent of ever pregnant women smoked and 18 percent consumed alcohol before their last or current pregnancy (upper panel Table 5.5.4). Although there was little difference by age, this was true for a greater percentage of urban women than rural women. Focusing on women who are currently pregnant, the lower panel of Table 5.5.4 shows that twice as many women under 25 smoked and drank just before the current pregnancy as compared to older pregnant women. Also, about three times as many urban women smoked just before the current pregnancy as compared to pregnant women in rural areas. While it is encouraging that fewer currently pregnant women smoked or drank "in the last 29 month" compared to "just before this pregnancy", the differentials according to age and residence were similar. IEC efforts to reduce these behaviors during pregnancy should be directed toward younger, urban women. Table 5.5.5 presents data on who attended at the births of children born in the last five years. More than 90 percent of births were attended by a doctor, trained nurse or trained midwife. Births among urban, lower parity women and women in higher educational and socio-economic categories were more likely to be attended by a doctor than a nurse or midwife. Although very few, less than 4 percent of births, were attended by a "nana" (traditional birth attendant), as might be expected, these were more likely to be births occurring among rural women in lower educational and socio-economic categories. Midwives as opposed to nurses were more likely to be used by older women and/or women in rural areas. The type of delivery in hospitals is shown for births in the past five years in Table 5.5.6. Caesarean sections (6.6%) are more likely to be performed among urban women, lower parity women and/or women in higher educational and socio-economic categories. Also, since the few women who give birth in private hospitals are more likely to be from these groups, the percentage of births delivered by Caesarean section in private hospitals (17.2%) is almost three times higher than the rate in government hospitals (6.1%). 30 NOTES 1. For a more detailed description of the Socio-Economic Index, see Administrative Report - Volume I, 1993 JAMAICA CPS; Appendix II (1994). [One in a series of five reports on the 1993 Contraceptive Prevalence Survey, published by the National Family Planning Board]. 2. For a more detailed description of the delineation of urban and rural areas, see Administrative Report - Volume I of this series, and, in particular, Table 1.4 (page 4). Also see the geographic boundaries of the health regions on page 1 of Volume I. 3. The relative effectiveness of the various contraceptive methods is discussed in: Hatcher, R. et. al., Contraceptive Technology, Sixteenth Revised Edition. Irvington Publishers: New York, NY, 1994. 4. In addition to continuation rates, the calendar allowed estimation of contraceptive failure rates. However, responses of contraceptive failure were very inconsistent and considered to be unreliable. For a discussion of the methodology used to calculate rates see Potter, R.G. Use-Effectiveness Of Intrauterine Contraception As A Problem In Competing Risks, in Family Planning In Taiwan: An Experiment In Social Change. R. Freedman and J. Takeshita, Princeton Univ. Press, 1969, pp. 458-484. 5. See, for example recent survey reports: Profamilia and Macro International. Columbia, Encuesta de Prevalencia. Demografia y Salud. 1990: National Statistics Office and Macro International. Philippines. National Demographic Survey. 1993. 6. Robey B., Rutstein, S.O., Morris, L., Blackburn, R. The Reproductive Revolution: New Survey Findings. Population Reports, Series M, No. 11. Baltimore, Johns Hopkins University, Population Information Program, December 1992. Cover VOLUME III: SEXUAL EXPERIENCE, CONTRACEPTIVE PRACTICE AND FERTILITY PREFACE CONTENTS LIST OF TABLES CHAPTER I: BACKGROUND 1.1 OBJECTIVES OF THE SURVEYS AND COVERAGE CHAPTER II: SEXUAL EXPERIENCE 2.1 - HISTORY OF SEXUAL EXPERIENCE 2.2 - CURRENT SEXUAL ACTIVITY Tables Table III-2.1.1 Table III-2.1.2 Table III-2.1.3 Table III-2.1.4 Table III-2.2.1 Table III-2.2.2 Table III-2.2.3 CHAPTER III: CONTRACEPTIVE USE 3.1 - EVER USE OF CONTRACEPTIVES 3.2 - CURRENT USE OF CONTRACEPTIVES 3.3 - CONTINUATION AND NON-USE OF CONTRACEPTION 3.4 - STERILIZATION - USE AND DEMAND 3.5 - WOMEN AND MEN IN NEED OF FAMILY PLANNING SERVICES Tables Table III-3.1.1 Table III-3.1.2 Table III-3.1.3 Table III-3.2.1 Table III-3.2.2 Table III-3.2.3 Table III-3.2.4 Table III-3.2.5 Table III-3.2.6 Table III-3.2.7 Table III-3.2.8 Table III-3.2.9 Table III-3.2.10 Table III-3.2.11 Table III-3.2.12 Table III-3.2.13 Table III-3.2.14 Table III-3.2.15 Table III-3.2.16 Table III-3.2.17 Table III-3.2.18 Table III-3.2.19 Table III-3.2.20 Table III-3.2.21 Table III-3.3.1 Table III-3.3.2 Table III-3.3.3 Table III-3.3.4 Table III-3.3.5 Table III-3.3.6 Table III-3.3.7 Table III-3.3.8 Table III-3.3.9 Table III-3.3.10 Table III-3.3.11 Table III-3.3.12 Table III-3.4.1 Table III-3.4.2 Table III-3.4.3 Table III-3.4.4 Table III-3.4.5 Table III-3.4.6 Table III-3.4.7 Table III-3.4.8 Table III-3.4.9 Table III-3.4.10 Table III-3.4.11 Table III-3.4.12 Table III-3.5.1 Table III-3.5.2 Table III-3.5.3 Table III-3.5.4 CHAPTER IV: AVAILABILITY AND COST OF CONTRACEPTIVE SERVICES 4.1 - SOURCE OF CONTRACEPTION 4.2 - WILLINGNESS TO PAY FOR CONTRACEPTIVES Tables Table III-4.1.1 Table III-4.1.2 Table III-4.1.3 Table III-4.1.4 Table III-4.1.5 Table III-4.2.1 Table III-4.2.2 CHAPTER V: FERTILITY 5.1 - GENERAL FACTORS INFLUENCING FERTILITY 5.2 - PLANNING STATUS OF LAST PREGNANCY 5.3 - CURRENT FERTILITY ESTIMATES 5.4 - BREASTFEEDING AND POSTPARTUM INSUSCEPTIBILITY 5.5 - MATERNAL HEALTH AND CHILD CARE Tables Table III-5.1.1 Table III-5.1.2 Table III-5.2.1 Table III-5.2.2 Table III-5.2.3 Table III-5.3.1 Table III-5.3.2 Table III-5.4.1 Table III-5.4.2 Table III-5.4.3 Table III-5.4.4 Table III-5.5.1 Table III-5.5.2 Table III-5.5.3 Table III-5.5.4 Table III-5.5.5 Table III-5.5.6 NOTES

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